MOiO 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


Digitized  by  the  Internet  Archive 

in  2007  with  funding  from 

IVIicrosoft  Corporation 


http://www.archive.org/details/essaysonsurgicalOOmoyniala 


«Oi  I  \ 


h.ssays  on 

Sur 

gical  Subjects 

SIR 

By 

BERKELEY  MOYNIHAN 

K.  C.  M.  G.,  C.  B. 
Leeds,  England 

Illustrated 

W. 

Philadelphia  and  London 

B.  Saunders  Company 

1921 

Copyright,  1921,  by  W.  B.  Saunders  Company 


PRINTED  IN  AMERICA 

PRESS  OF 

W.  B.  SAUNDERS  COMPANT 

PHIIiADELPHIA 


0Mne&a| 
Ukaxj 


WO 


To 
Dr.  W.  J.  Mayo 
Dr.  C.  H.  Mayo 

AND 

My  friends  at  the  Mayo  Clinic 

A  small  acknowledgment  of  a 

great  debt 


624000 


PREFACE 


This  book  contains  a  number  of  essays  that  have 
been  pubhshed  at  various  times  during  the  last  few 
years.  A  few  alterations  have  been  made,  and  the  sta- 
tistical figures  have  been  brought  up  to  the  end  of  the 
year  1920. 

The  pubhcation,  in  a  single  volume,  of  addresses, 
lectures,  and  essays  that  have  appeared  in  different 
journals,  and  at  varying  intervals  of  time,  may  find  its 
justification  in  that  it  presents  a  consecutive  train  of 
thought  and  experience  for ,  final  judgment.  And  I 
may  truthfully  plead  that  the  wishes  of  many  friends 
have  led  me  to  collect  these  scattered  articles  in  the 
present  little  book  which  I  offer  for  their  consideration. 

My  thanks  are  due  to  the  Editors  of  the  journals  in 
which  the  articles  originally  appeared  for  their  per- 
mission to  republish  them  here. 

Berkeley  Moynihan. 

33,  Park  Square,  Leeds, 
Augusi,  1921 


CONTENTS 

PAGE 

The  Murphy  Memorial  Oration 1 

The  Ritual  of  a  Surgical  Operation 45 

The  Diagnosis  and  Treatment  of  Chronic  Gastric  Ulcer    67 

Disappointments  After  Gastro-enterostomy Ill 

Intestinal  Stasis 131 

Acute  Emergencies  of  Abdominal  Disease 143 

The  Gifts  of  Surgery  to  Medicine 167 

The  Surgery  of  the  Chest  in  Relation  to  Retained  Pro- 
jectiles   197 

The  Most  Gentle  Profession 247 


Essays  on  Surgical  Subjects 


THE  MURPHY  MEMORIAL  ORATION* 

"The  moral  of  the  whole  story  is  this:  thai  vx  should  do  all  thai  we  can  to  pcwlake 
of  Virtue  and  Wisdom  in  this  life." — Socrates  is  speaking. 

This  is  a  day  of  remembrance.  We  have  come  to- 
gether to  do  honour  to  one  of  the  founders  of  this  College, 
a  great  surgeon  whose  loss  we  mourn.  You  have  laid 
upon  me  the  duty  and  the  high  privilege  of  oflFering  in 
your  name  and  in  my  own,  and  if  I  may  for  the  moment 
assume  a  wider  responsibility,  in  the  name  of  all  the 
surgeons  of  his  time,  a  tribute  to  the  illustrious  memory 
of  Dr.  J.  B.  Murphy. 

John  Benjamin  Murphy  was  an  arresting  personality. 
Even  after  the  briefest  intercourse  with  him  there  were 
few  people  who  did  not  reahze  that  he  possessed  a  curious 
and  subtle  power  of  impressing  a  sense  of  his  character 
upon  them.  His  very  handsome. face,  his  tall,  spare, 
almost  gaunt  figure,  his  high-pitched  and  vibrant  voice, 
his  burning  and  quenchless  enthusiasm  for  life  in  all  its 
manifold  activities,  his  power  of  complete  self-expression, 
all  clamoured  for  notice,  and  caught  and  held  the  most 
eager  attention.  His  outlook  was  grave  and  serious;  he 
seemed  always  in  earnest.  The  little  quips  and  sallies, 
the  friendly  taunts,  the  provocations  to  repartee,  the 
illuminating  anecdote,  which  in  the  United  States  dis- 

*  The  first  Murphy  memorial  oration  delivered  before  the  American  (College  of 
Surgeons,  at  Montreal,  October  11,  1920. 
i  i 


ESSAYS  ON  SURGICAL  SUBJECTS 


tinguish  the  cordial  intimacies  of  daily  life,  did  not  seem 
to  play  around  him  as  freely  as  around  other  men.  Even 
in  a  crowded  room  of  busy  men,  or  when  a  debate  was 
keen  he  would  steal  a  few  moments  for  a  whispered 
conversation,  held  aloof,  on  some  topic  that  for  the 
moment  filled  his  thoughts.  Among  those  who  knew  him 
well  he  was  admired  and  deeply  respected,  rather  than 
loved.  Except  to  a  very  few  he  was  not  genial  or  respon- 
sive in  friendship.  His  intellectual  attainments  were  so 
considerable,  and  his  position  in  the  judgment  of  his 
contemporaries  so  secure,  that  jealousy  hardly  touched 
him,  except  perhaps  in  his  earher  years  and  from  a  few 
among  his  seniors  whose  supremacy  he  challenged.  Such 
jealousy  is  perhaps  the  tribute  paid  to  youth  for  successful 
enterprise  in  thought  or  in  action  by  minds  which  suffer 
from  the  atheroma  of  advancing  years.  We  are  reminded 
of  the  aphorism  of  Sir  Walter  Raleigh 

"For  whoso  reaps  renown  above  the  rest 
With  heaps  of  hate  shedl  surely  be  opprest," 

Murphy  was  beyond  question  the  greatest  clinical 
teacher  of  his  day.  No  one  who  Ustened  to  him  can  ever 
forget  the  experience.  Before  his  audience  arrived  he 
had  everything  very  carefully  prepared,  diagrams  in 
order,  microscopes  ready,  the  patients  examined,  and  all 
relevant  literature  at  his  finger  ends.  There  he  stood  in 
the  middle  of  the  circle,  in  the  theatre,  with  his  assistants 
and  friends  in  the  first  row  and  the  other  benches  packed 
to  the  roof  with  eager  students,  or  with  medical  men, 
who  came  again  and  again  to  learn  from  him  afresh.  As  he 
began  to  speak  one  felt  a  strange  sense  of  disappointment, 
and  even  of  dismay.  For  while  the  handsome  face  and 
upright  figure  were  things  of  real  beauty,  the  voice  in 


THE  MURPHY  MEMORIAL  ORATION 


which  he  began  to  speak  was  quite  unpleasant.  It  was 
harsh,  even  raucous,  high  pitched,  shrill,  apt  to  wander 
into  other  keys.  It  seemed  strange  that  a  man  of  Irish 
descent,  and  of  so  gracious  and  commanding  a  presence, 
should  have  a  voice  so  lacking  in  softness,  one  which 
not  only  did  not  appeal,  but  actually  displeased  and 
almost  repelled  every  hstener.  But  as  he  continued 
speaking  the  voice  graduaUy  ceased  to  distract,  it  became 
smoother,  quieter,  and  more  evenly  pitched,  and  all 
thought  of  it  was  now  lost  in  rapt  attention  to  the  matter. 
For  things  were  happening  even  while  one's  first  emotions 
were  roused.  Questions  were  being  asked  and  answered, 
often  with  great  rapidity,  then  would  come  a  pause,  in 
which  with  marvellous  directness  and  power  the  lesson 
to  be  learnt  therefrom  was  driven  home.  The  rally  began 
again.  A  poor  answer  came,  or  an  assistant  responsible 
for  the  cHnical  notes  had  omitted  to  inquire  upon  some 
relevant  point;  raillery  came  in  torrents,  never  ill- 
natured,  never  rancorous,  but  with  just  sufficient  sting 
to  leave  a  memory  which  would  stimulate  all  future  work. 
The  discussion  warmed  imperceptibly;  gradually  the  co- 
herent chain  of  argument  lengthened,  as  fink  after  hnk, 
forged  under  our  eyes,  newly  appeared;  slowly  there 
came  a  sense  of  excitement;  of  impending  revelation;  all 
inquiry,  all  disclosure,  all  arguments,  were  leading  up  to 
something  that  we  now  ached  to  learn.  Old  observations 
and  ancient  truths  were  taking  on  a  new  complexion; 
relations  hitherto  unsuspected  were  here  declared  and 
explained.  The  whole  intellectual  mechanism  underlying 
a  great  subject  was  being  shewn  both  in  detail  and  in  all 
the  majesty  of  many  moving  parts.  Perhaps  as  we  drew 
near  to  the  end,  when  the  whole  story  would  be  laid 
bare,  a  question  barked  at  one  of  his  audience  would  fail 


ESSAYS  ON  SURGICAL  SUBJECTS 


to  be  answered.  With  voice  more  clamorous,  and  almost 
menacing,  with  face  strained  and  eager,  with  figure 
reaching  forward  and  arm  outstretched,  he  would  hurl 
the  question  at  others.  Hearts  beat  faster,  the  spiritual 
anguish  could  hardly  be  borne.  At  last  the  answer  would 
come,  and  after  a  final  swift  induction  or  brief  summary, 
when  the  clinical  journey  was  over,  we  sank  back  in 
happiness  and  mentgJ  repletion  to  wonder  if  Stevenson 
could  really  have  been  right  when  he  said,  "It  is  a  better 
thing  to  travel  hopefully  than  to  arrive,"  for  this  journey 
had  been  happy,  though  anxious  enough,  but  the  haven 
was  a  rest  of  tranquilhty,  and  wonder  and  content. 

And  then  Murphy  would  operate.  Now  of  operators 
there  are  many  types,  and  Kke  every  other  work  of  art, 
an  operation  is  the  expression  of  a  man's  temperment  and 
character.  There  are  still  among  us  "brilHant"  operators, 
from  whom  I  pray  to  be  spared  when  my  hour  has  come. 
For  them  it  is  the  mere  quahty  of  effort  that  counts. 
Their  ideed  of  operative  surgery  is  something  swift  and 
infinitely  dexterous,  something  to  dazzle  the  beholder, 
and  excite  his  wonder  that  such  things  can  so  be  done  by 
human  hands.  The  body  of  a  man  is  the  plastic  material 
in  which  an  artist  works,  and  no  art  is  worthy  of  such  a 
medium  unless  it  has  in  it  something  of  a  sacrament. 
Surgery  of  the  "briUiant"  kind  is  a  desecration.  Such  art 
finds  its  proper  scope  in  tricks  with  cards,  in  juggling  with 
billiard  balls,  and  nimble  encounters  with  bowls  of 
vanishing  gold  fish.  But  Murphy  was  of  the  true  faith. 
He  beheved  in  safe  and  thorough  work  rather  than  in 
specious  and  hazardous  briUiance.  He  was  infinitely  care- 
ful in  preparation,  and  compared  with  many  was  incHned 
to  be  slow;  but  every  step  in  every  operation  which  I  ever 
saw  him  do  was  completed  deliberately,  accurately,  once 


THE  MURPHY  MEMORIAL  ORATION  5 

for  all.  It  led  inevitably  to  the  next  step,  without  pause, 
without  haste;  that  step  completed,  another  followed. 
"In  sequent  toil  all  forwards  did  contend."  And  so  when 
the  end  came  a  review  of  the  operation  shewed  no  false 
move,  no  part  left  incomplete,  no  chance  of  disaster;  all 
was  honest,  safe,  simple;  it  was  modest  rather  than  bril- 
hant.  During  the  whole  operation  Murphy  talked;  not 
wasting  time,  but  expressing  and  explaining  aloud  the 
quiet,  gentle,  dexterous  movements  of  his  hands  and  the 
purposeful  working  of  his  mind.  The  operation  over, 
he  would  draw  his  stool  near  to  the  front  row  of  the 
benches,  cross  one  leg  over  another,  rest  his  elbow  on  his 
knee  and  talk,  as  only  he  in  all  the  world  could  talk,  of 
surgery  in  general,  of  this  case  in  particular,  of  his  faults, 
of  any  experiment  made  to  clear  a  doubtful  issue.  In 
these  quiet  talks  there  was  none  of  the  earher  passion 
which  had  gleamed  through  him,  and  which,  caught  up 
by  his  audience,  had  made  them  throb  and  tremble  with 
suspense  or  joy.  In  them  all  his  former  experience,  all 
that  he  had  learnt  by  contact  with  men  and  books,  aU 
his  native  ingenuity  of  mind,  were  now  bountifully  dis- 
played :  the  vast  resources  of  the  keenest  surgical  intellect 
of  his  day  were  now  disclosed,  not  with  ostentation  or 
with  florid  pride,  but  in  such  a  quiet  manner  as  to  shew 
that  he  rejoiced  in  the  privilege  of  sharing  with  others  so 
many  fascinating  and  wonderful  things.  If  in  answer  to  a 
request  a  httle  intellectual  gift  were  made  to  him,  it  was 
welcomed  with  frank,  almost  boyish  enthusiasm,  and  with 
a  dehght  and  humihty  obviously  genuine. 

Murphy  as  a  writer  and  as  a  speaker  was  prolific. 
Whenever  he  spoke  men  made  haste  to  hear  him.  His 
audience,  or  so  it  always  seemed  to  me,  were  often  held 
back  from  quick  appreciation.    He  was  not  like  other 


ESSAYS  ON  SURGICAL  SUBJECTS 


men  instantly  attractive  as  an  orator.  Yet,  as  he  devel- 
oped his  argument,  little  by  Httle,  and  step  by  step,  the 
audience  warmed  to  him,  he  interested  them,  he  in- 
trigued them,  he  dominated  them,  he  fired  them;  intellec- 
tually he  roused  them  to  breathless  interest;  emotionally 
they  were  at  times  at  the  hmit  of  self-control.  No  one 
could  bear  to  miss  a  word,  and  while  Murphy  spoke  no 
man  left  his  seat.  For  his  meaning  was  conveyed  in 
pellucid  language  and  though  he  might  speak  with  the 
vehemence  of  raging  conviction  his  thought  was  never 
obscured  in  a  smoke  of  words.  Such  an  intellectual  lode- 
stone  was  he  that  appointments  were  missed  and  hunger 
and  thirst  and  fatigue  were  forgotten.  For  while  Murphy 
expounded  his  gospel  everything  else  seemed  to  fade  in 
importance,  overshadowed  by  the  lessons  which  were 
now  being  learnt  so  eagerly. 

I  often  wondered,  as  I  hstened,  in  what  degree  he 
resembled  Lincoln.  The  tall,  gaunt  frame,  and  the  harsh 
and  meagre  and  strident  voice  were  the  same.  Murphy 
must  have  been  one  of  the  handsomest  men  of  his  day; 
Lincoln's  features  were  haggard,  plain  and  homely,  but 
his  deep  and  glowing,  sad  and  tender  eyes  no  man  could 
forget.  Murphy  had  no  such  command  of  language  as 
Lincoln,  certainly  one  of  the  greatest  orators  who  has 
ever  spoken  our  language.  But  in  effect  they  must  have 
been  alike.  For  they  made  everything  else  seem  common- 
place when  they  spoke,  and  they  seemed  to  be  deHvering 
a  message  charged  with  truth  and  pregnant  with  con- 
fidence and  hope.  Lord  Charnwood  in  his  most  excellent 
work  on  "Abraham  Lincoln"  writes  of  him:  "His  voice 
when  he  first  opened  his  mouth  surprised  and  jarred  upon 
the  hearers  with  a  harsh  note  of  curiously  high  pitch. 
But  it  was  the  sort  of  oddity  that  arrests  attention,  and 


THE  MURPHY  MEMORIAL  ORATION  7 

people's  attention  once  caught  was  apt  to  be  held  by  the 
man's  transparent  earnestness."  How  exactly  was  this 
the  case  with  Murphy  also  I  No  one  who  heard  Murphy 
speak  ever  doubted  his  sincerity.  One  might  not  agree; 
one  might  indeed  profoundly  and  confidently  disagree 
with  some  statement  he  made,  perhaps  as  though  to 
provoke  a  challenge,  for  there  was  much  in  Murphy  which 
justified  his  patronymic,  and  which  discovered  his  an- 
cestry; but  there  was  never  a  thought  that  Murphy 
himself  was  speaking  other  than  his  deep  and  tried  con- 
viction. He  never  looked  at  truth  askance  or  strangely. 
One  who  heard  Lincoln  speak  at  Peoria  wrote:  "Beyond 
and  above  all  skill  was  the  overwhelming  conviction 
imposed  upon  the  audience  that  the  speaker  himself  was 
charged  with  an  irresistible  and  inspiring  duty  to  his 
fellow  men."  Such  an  impression  was  often  felt  by 
audiences  while  Murphy  was  addressing  them. 

One  thing  Murphy  lacked ;  in  one  respect  he  grievously 
failed.  If  we  consider  the  quahties  which  go  to  the  mak- 
ing of  the  greatest  surgeons,  a  foremost  place  must  always 
be  conceded  to  the  capacity  to  train  great  disciples.  The 
teaching,  the  diUgence,  the  general  outlook  upon  surgery 
and  a  finished  technical  skill  can  all  be  drilled  into  the 
minds,  and  imposed  upon  the  methods  of  an  earnest 
student.  But  it  is  the  inspiration,  the  lofty  sense  of  a 
sacred  mission  worthy  of  all  the  best  that  is  in  you,  the 
dedication  with  humblest  and  fullest  devotion  to  the  cause 
of  scientific  truth,  and  of  loyal  service  to  mankind,  that 
are  awakened  with  a  thrill  in  great  men  by  great  teachers. 
It  is  here  that  Murphy  fell  short.  He  trained  no  one 
worthy  to  be  his  successor;  no  evangehst  who  could  carry 
into  other  chnics  or  to  other  countries  some  of  his  glow, 
his  fervour,  his  complete  devotion,  or  the  full  meaning  of 


ESSAYS  ON  SURGICAL  SUBJECTS 


his  gospel.  For  this  great  omission  there  were  periiaps 
some  compensations.  There  were  few  chnics  in  any  part 
of  the  world  in  which  something  taught  by  Mm'phy  or 
inspired  by  him  had  not  crept  in  and  found  a  home.  His 
name  was  often  on  the  hps  of  surgeons  in  all  lands.  His 
views  impressed  themselves  on  men's  minds.  His  methods 
were  closely  copied.  But  when  Murphy  laid  his  mantle 
down  there  was  no  one  ready  and  worthy  to  take  it  up. 
When  we  remember  how  the  pupils  of  Turner,  of  Edin- 
burgh, became  professors  in  most  of  the  chairs  of  anatomy 
throughout  the  British  Empire,  how  many  men  BiUroth 
trained  to  occupy  with  great  distinction  the  chairs  of 
surgery  in  eastern  Europe,  how  Welch  is  the  happy  parent 
of  a  great  school  of  pathologists  trained  by  him,  inspired 
by  him,  and  looking  to  him  with  reverent  affection,  we 
cannot  refrain  from  regret  that  some  of  the  acolytes  of 
Murphy  did.  not  grow  to  the  stature  of  High  Priests. 

Year  by  year  Mm'phy  grew  in  intellectual  power  and 
in  the  dominion  he  exercised  over  the  minds  of  men.  A 
problem  took  on  a  different  aspect  if  Murphy  were 
engaged  in  it.  He  touched  the  common  currency  of 
surgical  thought  and  changed  it  into  gold.  For  no  effort 
of  his  was  meaningless  or  sterile  and  all  the  powers  of  his 
mind  and  of  his  frail  body  were  spent  ungrudgingly  in  all 
his  work.  His  well  stocked  library,  and  all  new  hterature 
were  searched  for  him,  and  dispatches  made  for  his 
assimilation.  He  worked  as  all  great  men  should  work, 
with  a  clean  desk.  His  great  powers  were  used  for  worthy 
purposes  and  in  due  season,  nothing  was  wasted  in  mere 
hack  work,  for  all  that  could  be  equally  well  done  by 
others  was  left  for  them  to  do.  Yet  all  his  life  he  over- 
worked. He  had  an  inner  restless  spirit  which  drove 
him  at  full  speed.    He  must  work,  and  while  at  work 


THE  MURPHY  MEMORIAL  ORATION  9 

there  was  only  one  speed,  the  highest  he  could  command. 
"I  do  not  wish  to  hnger  after  my  work  is  done"  he  said, 
and  it  was  exactly  what  might  have  been  expected  from 
him. 

It  is  useless  to  wish  that  men  possessed  of  his  quaUties 
and  capacities  should  use  themselves  differently.  A  man 
must  do  as  he  must  do.  If  we  think  that  Murphy  by 
spending  himself  with  less  lavish  extravagance  might 
have  prolonged  his  life  another  ten  years  and  so  have 
achieved  even  greater  results,  to  the  benefit  of  all  man- 
kind, we  are  pondering  over  one  who  was  not  Murphy, 
and  who  could  not  in  those  early  fruitful  years  have 
been  so  avaricious  for  work,  or  have  so  generously  poured 
forth  the  new  truths  of  which  he  was  at  once  both  parent 
and  missionary.  Our  designs  for  another  man's  life  are 
but  futile  exercises  of  an  imagination  lacking  in  fuU  un- 
derstanding, and  adrift  from  realities. 

Such,  then,  was  Murphy  as  I  knew  him.  It  is  easy 
now  to  see  how  great  a  figure  he  was  in  the  world  of 
surgery  of  his  day.  When  all  his  work  is  reviewed,  when 
not  only  its  range,  but  the  wonderful  sincerity  and  the 
permanent  and  piercing  accuracy  of  so  large  a  part  of 
it  are  considered;  when  we  remember  his  unequalled 
gifts  as  teacher,  his  power  of  lucid  exposition  and  of 
persuasive,  or  coercive  argument,  his  devotion  for  many 
years  at  least  to  experimental  research,  it  is  no  exaggera- 
tion, I  think,  to  say  of  him  that  he  was  the  greatest  surgeon 
of  his  time.  Great  men  are  fitted  to  their  times  and  in 
many  respects  are  a  reflex  of  them.  But  as  their  times 
pass  their  work  is  seen  in  far  perspective  and  may  appear 
to  shrink  in  significance.  It  may  then  seem  to  have  lost 
all  its  originahty,  and  boldness,  and  force,  and  we  who 
stand  afar  off,  untouched  by  the  magnetism  of  a  great 


iO  ESSAYS  ON  SURGICAL  SUBJECTS 

personality,  marvel  at  its  influence  in  its  own  day.  For 
there  are  few  indeed  who  enjoy  both  celebrity  and  fame. 
*'Mere  talents  are  dry  leaves,  tossed  up  and  down  by  gusts 
of  passion  and  scattered  and  swept  away;  but  genius  lies 
on  the  bosom  of  Memory."  How  then  wiU  it  be  with 
Murphy?  Judged  by  the  standard  of  his  contemporaries 
he  was  an  intellectual  giant,  but  of  what  stature  will  he 
be  when  judged  by  the  standard  of  history?  May  I  ask 
you  to  bear  with  me  while  I  pass  briefly  in  review  some 
of  the  main  features  of  the  progress  of  surgery  as  science 
and  art  and  teU  the  tale  of  some  of  the  great  men  who  have 
laboured  in  it,  from  earliest  days  up  to  the  present  time, 
so  that  at  last  we  may  see  how  Murphy  stands  and 
what  figure  he  will  make  in  the  Great  Procession. 

The  earliest  remains  of  man  known  to  exist  shew 
that  the  art  of  the  surgeon  was  practised  upon  him. 
Wherever  skuUs  of  the  Neolithic  period  have  been  dis- 
covered the  openings  made  in  them  by  the  trepan  are  seen. 
Dr.  Marcel  Badouin,  in  1908,  found  within  a  tomb  dis- 
covered by  accident  at  BeUeville  the  remains  of  120 
human  beings.  Eight  of  the  skuUs  had  been  trepanned, 
and  the  edges  of  the  cut  bones  were  smoothly  healed  over, 
showing  beyond  doubt  that  the  patients  survived  the 
operation  for  periods  long  enough  for  this  to  be  fully 
accomphshed.  The  disc  of  bone  removed  is  supposed 
to  have  been  worn  as  an  amulet.  The  operation  of  tre- 
panning during  the  Neohthic  period,  was  also  performed 
in  England,  in  Northern  Africa,  the  Canary  Islands, 
Mexico,  and  in  Peru.  It  is  performed  today  by  the 
natives  of  New  Ireland,  to  the  east  of  New  Guinea,  by 
methods  and  with  results  apparently  similar  to  those  of 
the  Neohthic  age.  Dr.  Redman  has  presented  to  the 
Royal  College  of  Surgeons  of  England  a  group  of  five  skulls 


THE  MURPHY  MEMORIAL  ORATION  U 

shewing  the  effects  of  the  operation,  the  instruments 
by  which  it  is  there  performed,  and  the  dressings  appHed 
to  the  wound.  And  travellers  tell  us  that  the  operation  is 
still  practised  in  the  ancient  way,  so  far  as  can  be  judged, 
by  the  Quichuas  of  Peru.  Surgery  is  therefore  as  old  an 
art  as  any. 

Hippocrates  was  the  first  to  give  form  and  spirit  to  the 
practice  of  surgery.  His  observations  even  when  con- 
sidered with  the  fuller  knowledge  of  today  often  bewilder 
us  by  their  accuracy,  insight,  and  sagacity.  His  clinical 
methods  judged  by  our  modern  standards  were  broad- 
based  and  structurally  sound.  He  recognized  not  only 
the  nobihty  of  the  art  of  surgery,  and  the  worthiness  of 
its  practitioners,  but  was  well  aware  of  the  powerful 
influence  which  the  craft  must  exert  upon  the  science  of 
medicine.  The  divorce  of  hand  from  brain  which  modern 
custom  has  worked  hard  to  effect  derived  neither  sanction 
nor  authority  from  any  words  of  his.  As  he  deals  with  the 
outward  shewing  diseases  his  cHnical  method  is  everywhere 
the  same.  He  observes,  reflects,  weighs,  and  judges,  con- 
siders his  former  experience  of  the  like  or  analogous  con- 
ditions; he  suggests  or  discovers  a  general  truth;  he  lays 
down  principles  for  action,  and  he  tells  how  the  craftsman 
shall  work.  If  the  power  of  wide  and  accurate  general- 
ization be,  as  I  beheve  it  to  be,  among  the  supremest 
accompHshments  of  the  human  mind,  then  Hippocrates 
may  in  truth  be  said  to  have  had  few  rivals,  if  indeed  he 
has  had  any,  among  all  those  who  in  later  times,  and  in  all 
countries,  have  devoted  themselves  to  the  science  of 
medicine.  For  by  his  injunctions  as  to  the  method  of  en- 
quiry into  the  conditions  of  a  patient  suffering  from  any 
disease  he  lays  down  for  the  first  time  the  principles  upon 
which  inductive  research  is  founded.    He  is  the  parent 


12  ESSAYS  ON  SURGICAL  SUBJECTS 

not  of  medicine  alone,  but  of  the  inductive  method  as 
apphcable  to  all  branches  of  natural  science.  It  is  a 
proud  claim  that  the  method  found  its  first  apphcation 
in  the  science  of  medicine. 

His  observations  upon  cerebral  injuries  were  hardly 
bettered  until  our  own  day,  and  many  of  his  instructions 
as  to  their  treatment  cannot  be  neglected  even  now.  He 
notes  the  effect  of  brain  injuries  upon  the  limbs  of  the 
opposite  side.  His  work  on  fractures  and  dislocations  has 
received  praise  from  the  greatest  of  critics.  Littre  spoke 
of  it  as  "the  grandest  sm"gical  monument  of  antiquity" 
and  considered  that  the  truth  of  its  principles  was  eternal. 
A  century  ago  the  most  eminent  of  French  surgeons, 
Dupuytren,  published  a  work  on  "Dislocations."  Mal- 
gaigne,  whose  familiar  name  justly  carries  great  weight, 
judged  that,  in  respect  of  its  discussion  of  congenital  dis- 
locations, the  work  of  Hippocrates  was  the  richer  and  more 
accurate.  The  discourse  of  Hippocrates  on  "Wounds," 
which  I  read  once  again  in  the  early  weeks  of  the  War, 
seems  to  have,  in  more  relations  than  one,  a  bearing  upon 
our  bitter  experience  of  those  most  grievous  times.  Certain 
it  is  that  for  1500  years  afterward  nothing  so  apt  was 
written,  by  no  one  were  the  essential  problems  of  wound 
treatment  so  well  understood.  The  dressings  applied 
to  wounds,  he  tells  us,  were  to  be  of  new  materials;  water, 
if  not  clean  and  sweet,  was  to  be  boiled  and  strained  before 
use;  care  of  the  surgeon's  hands  and  nails  was  thought 
most  necessary.  Oil  and  wine  were  the  balsam  for  a 
bruised  or  dirty  wound;  or  for  one  long  neglected.  The 
accurate  apposition  of  the  wound  surfaces  and  the  exclu- 
sion of  air  were  means  to  secure  rapid  heaUng  by  "primary 
intention,"  which  was  clearly  distinguished  from  "second 
intention."    He  dreaded  amputation  of  a  Umb,  especially 


THE  MURPHY  MEMORIAL  ORATION  13 

near  the  trunk:  these  operations  today  are  in  respect  of 
their  mortality  still  among  the  most  lethal  of  all.  As  Sir 
John  Tweedy  has  said,  "The  directions  which  Hippocrates 
gives  concerning  the  arrangements  of  the  operating  room, 
the  placing  of  the  patient,  the  position  of  the  assistants, 
the  disposition  of  the  lighting,  the  care  to  be  taken  of  the 
sm'geon's  hands,  the  need  of  ambidexterity,  all  indicate  a 
careful  and  experienced  practitioner."  Hippocrates  may 
count  among  his  greatest  glories  that  he  recognized  the 
essential  unity  of  medicine  and  surgery,  or  rather  that  he 
did  not  distinguish  between  them:  that  he  urged  and 
practised  the  use  of  all  means  for  the  examination  of  the 
patient;  that  he  saw  no  degradation  as  did  so  many  later 
ages  in  the  use  of  a  physician's  hands  in  the  service  of 
the  individual  patient,  for  whose  welfare,  as  Aristotle  said, 
all  medicine  exists.  And  his  system,  which  embodied 
observation,  reflection,  judgment,  all  multiphed  to  make 
experience  which  shall  decide  right  action,  stands  firm 
until  this  day.  He  knew  its  difiBculties,  for  he  tells  us 
that  "experience  is  difficult,  verification  faUible,  observa- 
tion long  and  costly,  and  occasion  fleeting."  There  is  one 
gap,  however,  a  significant  one  in  view  of  my  later  con- 
tention, in  his  method.  He  did  not  put  matters  to  the 
proof  by  way  of  experiment.  The  experimental  verifica- 
tion or  denial  of  a  suggested  truth,  or  the  new  adventures 
in  thought  and  action  opened  up  by  this  method  were  not 
for  him. 

After  Hippocrates  we  may  take  a  long  stride  in  point  of 
time  to  the  days  of  Celsus,  who  Hved  in  the  reign  of 
Augustus  Caesar.  It  is  interesting  to  remember  that 
Celsus,  the  manuscript  of  whose  work  "DeRe  Medicina" 
written  about  30  A.  D.,  was  discovered  in  1443  in  the 
Church  of  St.  Ambrose  at  Milan  by  Thomas  of  Sezanne, 


iU  ESSAYS  ON  SURGICAL  SUBJECTS 

afterwards  Pope  Nicolas  V,  was  almost  certainly  not  a 
physician.  He  was  a  noble  of  the  family  of  CorneHi,  who 
wrote  works  on  medicine,  agricultm-e,  philosophy,  law, 
and  the  art  of  war,  in  the  spirit  of  an  interested  amateur. 
The  deep  prejudice  of  the  patricians  against  the  adoption, 
by  one  of  their  class,  of  medicine  as  a  profession  was  un- 
conquerable. And  the  internal  evidence  in  all  his  writings 
is  opposed  to  the  view  that  he  could  have  practised  as  a 
physician ;  he  mocks  at  the  value  of  medicine,  and  esteems 
the  empirical  methods  of  folk  medicine  as  of  equal  interest 
and  value  to  the  academic  methods  of  his  time.  He  tells 
us  that  the  true  art  of  medicine  lies  in  the  correlation  of 
theory  and  practice,  the  one  guiding  and  controlling  the 
other;  speculation  should  guide  thought  but  not  deter- 
mine practice.  References  to  surgical  matters  are  found 
in  all  the  books,  but  Books  VII  and  VIII  are  devoted 
exclusively  to  the  consideration  of  surgical  matters.  The 
great  feature  of  these  is  that  they  record  all  the  changes 
which  had  occurred  in  our  art  from  the  time  of  Hippocrates 
and  especially  informs  us  of  the  great  attainments  of  the 
Alexandrian  school  in  anatomy  and  surgery.  He  de- 
scribes wound  treatment  in  detail;  arrest  of  haemorrhage 
in  a  wound  may  be  effected  by  packing  and  pressure,  or  by 
the  ligature,  which  finds  its  first  mention  in  his  work. 
Sutures  are  to  be  used  to  secure  apposition  of  wound  sur- 
faces and  edges,  and,  as  a  dressing,  hnen  bandages  are  to 
be  soaked  in  wine,  water  or  vinegar.  He  gives  in  sufiicient 
detail  a  description  of  operations  for  the  radical  cure  of 
inguinal  and  umbilical  hernia;  and  for  the  first  time  he 
refers  to  the  removal  of  the  testis  as  allowing  a  firmer  and 
more  secure  closure  of  the  inguinal  canal.  He  mentions 
translucency  as  a  test  for  hydrocele,  and  describes  the 
tapping  of  dropsies.    He  quotes  a  large  number  of  surgical 


THE  MURPHY  MEMORIAL  ORATION  15 

authors,  but  among  them  all  only  Hippocrates  is  known 
to  us. 

It  is  evident  that  by  the  time  of  Celsus  the  boundaries 
of  surgery  had  been  sensibly  enlarged,  that  old  procedures 
had  been  bettered,  as  in  amputations,  and  that  many  new 
ones  had  been  devised.  But  progress  had  been  along 
the  old  lines,  and  was  achieved  by  the  old  methods.  He 
recorded  the  multiplication  and  the  magnification  of  old 
experiences  rather  than  the  revelation  of  new  discoveries. 
He  it  was  who  gave  us  the  fulfillment  of  the  promise  of  the 
Hippocratic  methods. 

But  great  as  were  these  methods,  and  considerable  as 
was  the  success  attending  their  appfication,  there  had 
been  a  slumber  of  the  intellectual  and  philosophical 
aspects  of  medicine.  Hippocrates  had  united  in  his 
own  person  many  divergent  and  opposing  tendencies; 
after  his  death  there  was  an  acceptance  of  his  teaching  by 
various  sects,  each  adopting  a  part  only,  and  dogmatism 
with  its  cramping  tendencies  crept  in  and  the  spirit  of 
investigation  died  away.  There  was  need  now  of  a 
philosopher  with  new  vision,  and  the  need  was  supplied 
by  Galen.  Of  Galen's  life  and  character  we  know  much, 
for  he  was  vain  and  ambitious,  garrulous  and  verbose. 
He  was  trained  and  deeply  versed  in  all  the  current 
philosophies.  A  dream  of  his  father,  Nikon,  interpreted 
as  a  vision  from  the  God  of  Medicine,  decided  his  choice  of 
a  profession.  After  the  death  of  his  father  he  wandered 
for  nine  years,  studying  in  Corinth,  Smyrna,  and  especially 
Alexandria,  which  then  attracted  commerce  and  patients 
from  all  parts  of  the  world.  His  opportunities  were  great 
and  his  use  of  them  unwearying.  He  wrote  works  on 
anatomical  and  physiological  matters,  and  attained 
even  in  these  early  years  of  his  a  reputation  for  wisdom  and 


16  ESSAYS  ON  SURGICAL  SUBJECTS 

sagacity.  For  four  years  he  lived  in  Rome.  His  learning, 
his  industry,  his  friendship  with  the  great  and  the  noble, 
brought  him  high  repute.  But  the  envy  of  his  colleagues, 
which  he  did  much  to  provoke,  was  his  downfall  and  he 
fled  in  fear  of  his  life,  to  return  on  the  invitation  of  Marcus 
Aurelius  some  twelve  years  later.  But  Galen's  chief 
claim  to  honour,  an  imperishable  one,  is  that  he  was  the 
first  of  physicians  to  bring  experiment  to  the  aid  of 
medicine.  As  Hippocrates  was  the  parent  of  inductive 
method,  so  was  Galen  of  the  deductive.  He  was  the  first 
experimental  physiologist.  It  was  he  who  first  discovered 
and  described  the  cranial  nerves,  and  the  sympathetic 
nervous  system;  he  divided  the  spinal  cord  and  produced 
paraplegia;  he  severed  the  recurrent  laryngeal  nerve,  and 
produced  the  hoarseness  and  aphonia,  which  are  the 
constant  results  of  this  injury.  He  discovered  the  func- 
tion of  a  muscle  by  studying  the  loss  of  power  which  fol- 
lowed its  division.  He  demonstrated  the  flow  of  urine 
from  the  kidney  to  the  bladder  along  the  ureters,  by  a 
series  of  experiments  than  which  nothing  today  could  be 
more  conclusive.  And  he  trembled  at  the  very  edge  of  a 
great  discovery  when  he  wrote:  "If  you  would  kiU  an 
animal  by  cutting  through  a  number  of  its  large  arteries 
you  wiU  find  the  veins  becoming  empty  along  with  the 
arteries;  now  this  could  never  occur  if  there  were  not 
anastomoses  between  them."  Unhappily  experiment 
alone  did  not  content  him,  nor  experiment  in  close  aUiance 
with  clinic£j  observation.  His  knowledge  of  anatomy, 
unsurpassed  by  any  of  his  time,  did  not  keep  him  aloof 
from  the  wfldest  speculations  in  natural  philosophy.  It  is 
interesting  to  learn  from  him  that  the  art  of  dissection  was 
mainly,  if  not  wholly,  confined  to  certain  famflies,  among 
whom  tradition  and  instruction  give  rise  to  a  caste  of 


THE  MURPHY  MEMORIAL  ORATION  i7 

dissectors.  The  members  of  a  family  were,  from  their 
childhood,  exercised  by  their  parents  in  dissecting,  just  as 
familiarly  as  in  writing  and  reading,  so  that  "there  was  no 
more  fear  of  their  forgetting  their  anatomy  than  of  for- 
getting their  alphabet." 

Galen's  dissections  were  confined  to  the  bodies  of 
animals,  and  the  facts  so  discovered  were  appHed  by  anal- 
ogy only  to  the  bodies  of  men.  If  a  physiological  hy- 
pothesis charmed  him,  his  anatomical  observations  had  to 
give  way  to  it.  His  mind  ran  riot  in  speculation,  often  fan- 
tastic and  far-fetched,  but  occasionally  shewing  a  gleam 
of  real  insight,  as,  for  example,  in  his  belief  that  there 
was  a  close  primary  correspondence  between  the  sexual 
organs  of  the  male  and  female.  But  the  evils  were 
great  and  lasting.  It  was  his  rash  conceits  rather  than 
the  facts  of  his  experiments,  or  his  sound  anatomical 
knowledge,  and  broad  scientific  purpose  which  were 
remembered,  and  indeed  almost  sanctified,  by  all  men 
for  a  period  of  over  1500  years.  Though  he  was  the  first 
of  experimenters  he  asserted  that  speculation  should  lead 
experience  and  he  exalted  a  debased  metaphysics  to  a 
height  exceeding  that  of  strict  and  sober  observation. 
In  the  times  of  intellectual  stagnation  in  the  Dark  Ages 
the  writings  of  Galen  had  an  enequalled  authority;  and 
it  was  only  by  a  notable  independence  that  AbdoUatif 
dared  to  assert  that  anatomy  was  not  to  be  learnt  from 
books  and  that  even  Galen's  observations  were  less 
to  be  trusted  than  the  evidences  of  one's  own  senses.  The 
result  was  the  sterihty  and  the  abasement  of  medicine 
until  the  experimental  methods  were  revived  by  his  direct 
intellectual  descendant,  WiUiam  Harvey. 

In  a  rather  diflferent  sense,  and  in  a  different  scene,  the 
great  traditions  of  medicine  were  handed  on  by  Avicenna, 


18  ESSAYS  ON  SURGICAL  SUBJECTS 

who  was  born  in  Bokhara  about  980  A.  D.  It  was  through 
him  that  the  works  of  Hippocrates  and  Galen  became 
widely  known  through  the  East,  and  finally  filtered  back 
to  Europe  through  the  Arabs  and  Moors  at  a  time  when 
learning  and  culture  had  almost  vanished.  The  Arabian 
mind  was  essentially  concerned  with  compiUng  knowledge 
from  all  sources  rather  than  in  initiating  enquiry;  and  a 
great  and  useful  work,  in  this  direction,  was  carried  out 
by  them  during  the  brightest  days  of  the  Saracen  Empire. 
The  modern  world  indeed  owes  much  to  their  careful 
preservation  of  knowledge  and  their  multiphcation  of 
copies  of  standard  medical  works,  before  the  era  of  print- 
ing; even  though  the  science  and  art  of  medicine  in  itself 
did  not,  through  their  efforts,  advance  one  step.  In 
Avicenna  we  find  a  mind  as  keen  as  that  of  his  great 
predecessors,  viewing  the  human  body  and  its  ailments 
in  his  own  way,  although  numerous  points  of  resemblance 
to  the  works  of  Galen  and  Hippocrates  are  everywhere 
evident.  He  was  not  an  experimenter  so  much  as  a 
philosopher  and  the  power  of  his  mind  over  so  many  later 
centuries  is  probably  to  be  attributed  to  his  masterly  grasp 
of  all  sciences  as  well  as  of  medicine  and  surgery.  In  the 
art  of  surgery  he  can  hardly  have  attained  the  skill  of  the 
great  founder,  as  far  as  can  be  judged  by  the  records  in  the 
Canon.  We  do  not  find  all  those  evidences  of  mastership 
in  technique  which  shine  so  strongly  through  the  writings 
of  Hippocrates.  As  is  characteristic  of  the  Eastern  today 
the  knowledge  which  he  possessed  and,  to  judge  by  the 
records  of  his  successes,  utihzed  with  great  practical 
effect,  was  of  a  different  order,  both  intuitive  and  logical, 
but  intuitive  before  logical.  His  skill  in  deafing  with 
fundamental  mathematical  problems  is  hardly  surpassed 
at  the  present  day,  and  in  this  respect  he  has  been  almost 


THE  MURPHY  MEMORIAL  ORATION  19 

the  only  instance  of  a  great  mind  applying  mathematical 
concepts  to  medicine  and  surgery,  up  till  the  present  era. 

Of  other  writers  before  the  sixteenth  century,  it  is  not 
unfair  to  say  that  they  all,  or  almost  all,  were  merely 
recorders,  encyclopaedists  it  may  be,  but  devoid  of  any 
spark  of  new  thought  or  of  wise  generalization.  They 
preserved  with  reverence  the  old  tradition  and  the  ancient 
knowledge,  they  discussed  every  device,  and,  at  intermin- 
able length,  the  meanings  of  the  old  scriptures;  they 
tortured  new  meanings  out  of  old  phrases,  they  were 
diligent  in  dressing  old  words  new,  and  their  scholarship 
was  judged  by  their  ingenuity,  or  infinite  prolixity,  in  so 
doing. 

The  anatomists  of  the  Middle  Ages  prepared  the  way 
for  new  enhghtenment.  The  oldest  treatise  on  anatomy 
comes  from  Egypt.  The  papyrus  dates  probably  from 
the  reign  of  Thutmosis  I,  that  is,  from  before  the  crossing 
of  the  Red  Sea  by  the  Israelites.  It  shews  the  heart  with 
vessels  proceeding  from  it,  the  hver,  spleen,  kidneys,  ure- 
ters, and  bladder.  The  first  of  comparative  anatomists 
was  Aristotle.  The  expedition  of  his  pupil  Alexander 
into  Asia,  which  he  accompanied,  gave  him  unprecedented 
opportunities  for  the  study  of  many  animals;  the  result 
of  his  work  is  contained  in  several  books.  The  first 
dissections  of  the  human  body  were  made  by  Erasistratus 
and  Herophilus,  of  Alexandria.  Under  the  Ptolemies  in 
Egypt  were  garnered  all  the  fading  philosophies  and  sci- 
ences which  amid  the  dissensions  and  distractions  of  life 
in  Greece,  could  no  longer  flourish  there.  Alexandria 
then  became  the  guardian  and  the  host  of  all  the  sciences 
and  the  hteratures  of  the  world.  It  was  here,  as  we  have 
seen,  that  Galen  learnt  much  of  his  anatomy. 

After  the  darkness  of  succeeding  centuries  the  first 


20  ESSAYS  ON  SURGICAL  SUBJECTS 

gleam  of  dawn  was  seen  in  the  University  of  Bologna. 
For  over  100  years  it  had  been  renowned  as  a  centre  of 
scholastic  knowledge,  of  Uterature  and  of  law.  Mondinus, 
the  father  of  anatomy  as  he  is  always  acclaimed,  lectured 
there  between  1315  and  1325,  and  pubHcly  demonstrated 
the  structm'es  of  the  body  as  disclosed  by  dissection.  His 
descriptions  are  remarkable  alike  for  their  extent  and  their 
accuracy.  The  claim  has  been  made  for  him  that  he  went 
near  to  the  discovery  of  the  circulation  of  the  blood,  for 
he  says  that  the  heart  drives  or  transmits  the  blood  to  the 
lungs.  Two  centuries  later  (1514-1564)  was  bom  the 
greatest  of  all  anatomists,  Andreas  Vesahus,  a  native  of 
Brussels,  a  student  at  Lou  vain.  The  difficulties  of  per- 
forming dissections  were  so  great  in  France  that  he  went 
to  Italy  for  freer  and  larger  opportunities.  "My  study  of 
anatomy,"  he  says,  "would  never  have  succeeded  had  I, 
when  working  at  medicine  in  Paris,  been  wiUing  that  the 
viscera  should  be  merely  shewn  to  me  and  to  my  fellow 
students  at  one  or  another  public  dissection,  by  wholly 
unskilled  barbers,  and  that  in  the  most  superficial  way. 
I  had  to  put  my  own  hand  to  the  business."  When 
twenty-one  years  of  age  he  was  asked  to  lecture  at  the 
University  of  Padua.  His  original  additions  to  the 
science  of  anatomy  were  numerous  and  of  the  highest 
importance.  He  swept  away  much  of  the  old  '  'analogical' ' 
anatomy,  the  surmises  and  the  errors,  hoary  with  age,  and 
sanctified  by  their  free  acceptance  by  a  multitude  of 
authors  in  the  centuries  after  Galen  formulated  them. 
His  work  on  anatomy  is  adorned  with  illustrations  which 
for  beauty  of  design  and  accuracy  of  execution  have  never 
been  surpassed,  indeed,  I  think  not  equalled,  since  they 
were  pubfished.  It  is  said  that  the  figures  were  drawn  by 
Titian.     Cuvier  remarks  that  if  this  be  not  true  they 


THE  MURPHY  MEMORIAL  ORATION  21 

must  at  least  be  the  work  of  one  of  his  most  distinguished 
pupils.  But  Vesalius  did  something  more  than  all  this. 
He  was  the  first  imitator  of  Galen  in  experimental  work, 
and  though  he  did  little  enough,  it  was  sufficient  to  show 
that  the  method  was  not  utterly  forgotten.  He  was  the 
forerunner  of  those  distinguished  Itahan  anatomists  who 
may  share  with  him  the  credit  for  the  creation  of  the 
science  of  anatomy,  of  Eustachius,  of  Fallopius,  who  in  his 
short  life  labored  to  great  ends,  and  of  Fabricius,  his 
successor  in  the  chair  of  anatomy  and  surgery  of  Padua, 
among  whose  pupils  was  William  Harvey.  The  presence 
of  folds  in  the  interior  of  some  veins  had  been  noted  by 
Sylvius  and  Vesahus  and  others,  and  those  of  the  vena 
azygos  were  particularly  described  by  Canani  in  1547, 
but  it  was  Fabricius  who  recognized  the  existence  of 
valves  throughout  the  venous  system  and  who  observed 
that  they  were  all  turned  towards  the  heart. 

Harvey  had  been  attracted  by  the  fame  of  Fabricius  to 
Padua,  at  a  time  when  Gahleo  was  teaching  and  was  en- 
gaging in  those  methodical  researches  whose  influences 
have  lasted  to  our  own  day.  Harvey  said  of  himself  that 
he  felt  it  in  some  sort  criminal  to  call  in  question  doctrines 
that  had  descended  through  a  long  succession  of  ages  and 
carried  the  authority  of  ancients,  but  he  "appealed  unto 
Nature  that  bowed  to  no  antiquity,  and  was  of  still  higher 
authority  than  the  ancients."  It  was  at  the  instigation  of 
Fabricius  that  Harvey  undertook  by  experiment  to  dis- 
cover the  function  of  the  valves  in  the  venous  system,  and 
in  the  year  of  Shakespeare's  death  those  experiments  whose 
end  was  to  bring  about  the  greatest  discovery  in  the  history 
of  medicine  were  begun.  The  discovery  had  almost  been 
made  by  half  a  dozen  of  his  predecessors  who  appeared  to 
haye  stood  upon  its  very  brink.    As  Cuvier  says,  we  are 


22  ESSAYS  ON  SURGICAL  SUBJECTS 

often  on  the  edge  of  discovery  without  suspecting  it. 
There  can  be  Httle  doubt  that  the  puhnonary  circulation 
had  been  recognized  by  the  unhappy  Servetus,  who,  with 
his  works,  was  burned  as  a  heretic  at  Geneva  in  1553  by 
Calvin. 

In  1559,  a  pupil  of  Vesalius  at  Padua,  Realdus  Colum- 
bus, may  be  said  to  have  suggested  the  existence  of  this 
circulation  by  inductive  reasoning,  but  to  ingenious 
speculation  the  minds  of  men  were  hardened.  It  was 
open  demonstration  and  proof  that  were  needed  to  press 
home  an  opinion  so  contrary  to  all  accepted  teaching. 

A  discovery  is  rarely,  if  ever,  a  sudden  achievement, 
nor  is  it  the  work  of  one  man ;  a  long  series  of  observations 
each  in  tm*n  received  in  doubt,  and  discussed  in  hostility, 
are  famiharized  by  time,  and  lead  at  last  to  the  gradual 
disclosure  of  the  truth.  Harvey's  discovery  was  finally 
due  to  his  application  of  the  experimental  method  of 
Archimedes  and  Galen  to  a  problem  of  which  many  of 
the  factors  were  gJready  known ;  or,  as  he  himself  tells  us, 
the  circulation  of  the  blood  was  held  to  be  completely 
demonstrated  by  experiment,  observation,  and  ocular 
inspection  against  all  force  and  array  of  argument.  He 
writes:  "When  I  first  gave  my  mind  to  vivisections,  as  a 
means  of  discovering  the  motions  and  uses  of  the  heart 
and  sought  to  discover  these  from  actual  inspection  and 
not  from  the  writings  of  others,  I  found  the  task  so  truly 
arduous,  so  full  of  difficulties,  that  I  was  almost  tempted 
to  think  with  Fracastorius,  that  the  motion  of  the  heart 
was  only  to  be  comprehended  by  God.  ...  At  length 
and  by  using  greater  and  daily  dihgence,  having  frequent 
recourse  to  vivisections,  employing  a  variety  of  animals  for 
the  purpose,  and  collecting  numerous  observations,  I 
thought  that  I  had  attained  to  the  truth." 


THE  MURPHY  MEMORIAL  ORATION  23 

The  reception  of  this  discovery  was  generous  at  home ; 
tardy  and  reluctant,  or  openly  hostile  abroad.  But  it 
was  everywhere  eagerly  and  hotly  discussed.  Harvey 
says:  "But  scarce  an  hour  has  passed  since  the  birthday 
of  the  circulation  of  the  blood  that  I  have  not  heard  some- 
thing for  good  and  for  evil  said  of  this  my  discovery. 
Some  abuse  it  as  a  feeble  infant,  and  yet  unworthy  to 
have  seen  the  hght;  others  again  think  the  banthng  de- 
serves to  be  cherished  and  cared  for.  These  oppose  it 
with  much  ado,  those  patronize  it  with  abundant  com- 
mendation." 

Biolan,  distinguished  as  an  anatomist,  and  professor  at 
the  College  de  France,  denied  and  derided  it.  What 
Harvey  felt  of  the  opposition  may  be  learnt  from  his 
reply  to  a  friend  who  urged  upon  him  the  pubHcation  of 
his  later  work,  De  Generatione  Animalium:  "And  would 
you  advise  me  to  quit  the  tranquillity  of  this  haven, 
wherein  I  now  calmly  spend  my  days  and  again  commit 
myself  to  the  unfaithful  ocean?  You  are  not  ignorant 
how  great  troubles  my  lucubrations,  formerly  pubUshed, 
have  raised.  Better  it  is  certainly,  at  some  time,  to  en- 
deavour to  grow  wise  at  home  in  private  than  by  the  hasty 
divulgation  of  such  things,  to  the  knowledge  whereof  you 
have  attained  with  vast  labour,  to  stir  up  tempests  that 
may  deprive  you  of  your  leisure  and  quiet  for  the  future." 
Nevertheless,  compensations  and  rewards  came  to  him  in 
full  measure,  and  he  had  the  satisfaction  of  Hving  to 
see  the  general  acceptance  of  his  discoveries.  This  dis- 
covery, as  Whewell  said,  implied  the  usual  conditions, 
distinct  general  notions,  careful  observation  of  many 
facts,  and  the  mental  act  of  bringing  together  these 
elements  of  truth.  Boyle  wrote:  "I  remember  that  when 
I  asked  our  famous  Harvey  what  were  the  things  that 


24  ESSAYS  ON  SURGICAL  SUBJECTS 

induced  him  to  think  of  a  circulation  of  the  blood,  he 
answered  me  that  when  he  took  notice  that  the  valves  in 
the  veins  of  so  many  parts  of  the  body  were  so  placed  that 
they  gave  a  free  passage  to  the  blood  toward  the  heart, 
but  opposed  the  passage  of  the  venal  blood  the  contrary 
way,  he  was  incited  to  imagine  that  so  provident  a  cause 
as  Nature  had  not  placed  so  many  valves  without  design ; 
and  no  design  seemed  more  probable  than  that  the  blood 
should  be  sent  through  the  arteries  and  return  through 
the  veins  whose  valves  did  not  oppose  its  course  that  way. 
That  supposition  his  experiments  confirmed." 

But  the  experimental  methods  of  Galen,  revived  by 
Gilbert,  physician  to  Queeen  Elizabeth  and  the  father  of 
modem  experimental  science,  and  practised  with  such 
supreme  effect  by  Harvey,  was  to  find  as  yet  no  place  in 
scientific  surgery.  That  art  it  is  true  was  practised  with 
wider  scope,  with  confidence  bred  of  generations  of 
experience,  and  with  a  risk  that  was  perhaps  steadily, 
though  almost  neghgibly,  diminishing.  Safety  was  rather 
dependent  upon  the  individual  capacity  of  the  surgeon 
than  a  quality  common  to  the  work  of  all.  Richard 
Wiseman,  who  was  born  three  years  after  the  pubHcation 
of  Harvey's  discovery,  is  generally  granted  the  proud 
title  of  the  Father  of  English  surgery.  He  was  a  man 
"given  to  the  observation  of  Nature"  and  became  Sergeant 
Surgeon  to  Charles  H  and  to  James  H  (who  when  Prince 
of  Wales  and  Duke  of  York  were  withdrawn  under  a 
hedge  during  the  battle  of  Edgehill,  October  23, 1642,  when 
Harvey  distracted  their  thoughts  by  reading  to  them), 
and  among  his  contributions  to  the  craft  of  surgery  may 
be  mentioned  his  operations  for  hernia,  and  his  advocacy 
of  primary  amputation  in  cases  of  injury,  by  gunshot  or 
otherwise,  of  the  limbs. 


THE  MURPHY  MEMORIAL  ORATION  25 

Ambrose  Pare  was  to  French  surgery  what  Wiseman 
was  to  British.  The  life  of  Pare  is  one  of  the  greatest 
romances  in  the  history  of  our  profession;  it  tells  the 
story  of  the  progress  of  the  son  of  a  joiner  who  was 
groom,  gardener,  barber's  apprentice,  until  he  became 
at  last  the  surgeon  to  four  kings  of  France.  It  was  he 
who  was  concealed,  locked  up  in  a  room  of  the  Louvre, 
and  spared  from  death  by  special  order  of  Charles  IX 
at  the  Massacre  of  the  Huguenots  on  the  day  of  St. 
Bartholomew.  For  the  King  said  that  it  was  not  reason- 
able that  a  man  who  was  worth  a  whole  world  of  men 
should  be  murdered.  He  is  the  outstanding  medical 
figure  in  the  Renaissance.  He  was  untaught  and  there- 
fore in  youth  at  least  free  from  the  tranamels  of  ancient 
lore.  Early  in  life  he  said :  "I  make  no  claim  to  have  read 
Galen  either  in  Greek  or  in  Latin;  for  it  did  not  please 
God  to  be  so  gracious  to  my  youth  that  it  should  be  in- 
structed either  in  the  one  tongue  or  in  the  other."  At 
last  when  he  read  Hippocrates  and  Galen  he  surpassed 
them  both  in  the  niunber  and  variety  of  the  conditions  he 
had  been  called  upon  to  treat;  and  he  was  therefore 
the  better  fitted  to  approach  their  teaching  in  the  spirit  of 
an  informed  and  practised  critic.  "We  must  not  be 
drugged  by  the  work  of  the  ancients  as  if  they  had  known 
all  things  or  spoken  all,"  he  writes.  Yet  in  later  years 
he  studied  dihgently,  for  he  was  said  by  Thomas  Johnson, 
who  translated  and  edited  his  works,  to  be  "a  man  very 
well  versed  in  the  writings  of  the  ancient  and  modem 
physicians  and  surgeons."  He  was  one  of  the  greatest 
original  minds  our  art  has  known,  fearless,  independent, 
alert  and  inventive,  and  not  without  a  good  conceit. 
"There  be  few  men  of  this  profession,"  he  writes,  "which 
can  bring  so  much  authority  to  their  writings  either  with 


26  ESSAYS  ON  SURGICAL  SUBJECTS 

reason  or  experience  as  I  can,"  and  again,  "I  have  so 
certainly  touched  the  mark  whereat  I  aimed  that  antiq- 
uity may  seem  to  have  nothing  wherein  it  may  exceed  us 
beside  the  glory  of  invention,  nor  posterity  anything  left 
but  a  certain  small  hope  to  add  some  things  as  it  is  easy 
to  add  to  former  inventions."  He  won  for  surgery  and 
for  those  who  practised  the  craft  in  France  a  place  they 
had  never  before  attained. 

Surgery  was  still  lacking  its  firm  foundation  in  patho- 
logical anatomy.  This  was  to  be  built  by  Morgagni  and 
John  Hunter  and  by  many  others  taught  and  inspired  by 
them.  The  tireless  industry,  unwearying  care,  and  pro- 
found sagacity  of  John  Hunter  gave  to  an  art  that  was 
largely  empirical  a  warrant  based  upon  a  sound  knowledge 
of  morbid  processes  in  all  tissues.  He  was  observer, 
investigator,  collector,  in  each  capacity  without  a  rival. 
He  was  unceasing  in  his  search  for  truth  by  way  of  ex- 
periment. "Don't  think,  try  the  experiment,"  he  urged 
his  pupil  Jenner.  In  his  own  person  he  did  both  su- 
premely well.  His  disregard  of  the  written  word  was 
deplorable  no  doubt,  but  refreshing  after  so  much  b£U"ren 
speculation  among  his  forerunners.  *T  am  not  a  reader 
of  books,"  he  said;  and  again,  "I  beheve  nothing  I  have 
not  seen  and  observed  myself."  His  rebuff  to  one  who 
accused  him  of  ignorance  of  the  classics  is  famous:  "Jesse 
Foot  accuses  me  of  not  understanding  the  dead  languages, 
but  I  could  teach  him  that  on  the  dead  body  which  he 
never  knew  in  any  language,  dead  or  Hving."  Often  he 
recounts  the  details  of  an  experiment,  but  leaves  us  to  draw 
the  conclusion.  He  changed  the  whole  spirit  of  practice 
and  placed  knowledge  on  the  throne  of  authority.  The 
day  was  gone  forever  when  a  pure  and  dangerous  em- 
piricism could  be  practised ;  surgery  became  a  science  and 


THE  MURPHY  MEMORIAL  ORATION  27 

its  craft  a  rational  procedure.  The  museum  which  he 
founded  and  which  still  bears  his  name  in  the  Royal  College 
of  Surgeons  of  England  is  unsurpassed  in  all  the  world, 
and  his  own  specimens  are  still  to  be  seen  to  bear  witness 
to  his  incomparable  services  to  pathological  anatomy. 
For  Morgagni  no  praise  can  be  too  high.  His  letters  may 
be  read  today  with  dehght;  though  his  knowledge  of 
disease  is,  in  the  modern  view,  often  steeped  in  mediaeval- 
ism,  his  long  array  of  facts  and  of  relevant  instances,  his 
description  of  morbid  parts,  his  accurate  and  searching 
generalizations  are  among  the  greatest  contributions  to 
medical  literature  in  all  the  ages. 

Such  was  the  progress  of  surgery  up  to  the  early  years 
of  the  nineteenth  century.  The  discovery  of  the  anaes- 
thetic properties  of  ether  and  chloroform  completely 
changed  the  possibihties  of  the  range  of  appHcation  of 
surgery  to  morbid  conditions  and  enlarged  also  the  scope 
of  experimental  work  upon  animals.  But  in  every  direc- 
tion the  surgeon's  work  was  hampered  and  frustrated  by 
the  occurrence  of  infection  and  all  its  dire  consequences, 
in  the  majority  of  the  wounds  inflicted.  It  was  for  Lister 
that  the  world  was  waiting  and  his  coming  changed  every- 
thing. For,  as  Carlyle  said,  *'The  great  man  was  always  as 
lightning  out  of  Heaven :  the  rest  of  men  waited  for  him 
hke  fuel,  and  then  they  too  would  flame." 

Lister,  as  every  one  knows,  introduced  the  antiseptic 
system  into  surgery.  Before  his  time  the  wounds  inflicted 
by  the  surgeon,  or  those  received  in  civil  life  as  in  cases  of 
compound  fracture,  became  septic  almost  as  a  matter  of 
course.  The  decomposition  of  the  wound  discharges  was 
formerly  held  to  be  due  to  contact  with  the  oxygen  of  the 
air.  Lister  recognized  that  the  investigation  of  many 
observers,  ending  with  Pasteur,  which  shewed  that  far- 


25  ESSAYS  ON  SURGICAL  SUBJECTS 

mentative  and  putrefactive  processes  depended  upon 
minute  organisms,  were  applicable  in  surgical  work  also. 
In  the  year  1836,  a  French  observer,  G.  Latour,  had 
pointed  out  that  the  tiny  particles  of  which  yeast  was 
composed  were  capable  of  multipUcation,  that  they  were 
in  fact  £dive,  and  that  it  was  by  their  propagation  that  the 
change  known  as  fermentation,  the  change  of  sugar  into 
alcohol,  was  produced.  Both  Latour  and  T.  Schwann 
shewed  that  this  process  could  be  suppressed  by  the 
appHcation  of  heat  to  the  yeast.  Schwann,  especially, 
called  attention  to  the  fact  that  the  putrefaction  of 
organic  substances  was  due  to  these  minute  living  bodies, 
and  that  putrefaction  and  fermentation  were  essentially 
one.  The  weighty  authority  of  Liebig  was  opposed  to  this 
view,  and  Helmholtz,  after  a  time  of  wavering,  finally 
ranged  himself  against  Schwann.  It  was  in  1856  that 
Pasteur  began  the  series  of  experiments  which  demon- 
strated finally  that  micro-organisms  were  the  cause  of 
fermentation  and  of  putrefaction,  and  that  for  each  form 
of  fermentation  studied  by  him — yeast  fermentation, 
lactic  acid  fermentation,  butyric  acid  fermentation — there 
was  one  specific  cause,  and  only  one. 

Lister  had  long  been  working  on  the  problem  of  in- 
flanmiation  and  of  the  decomposition  of  wound  discharges. 
When,  therefore,  early  in  1865  he  read  of  the  work  of 
Pasteur  his  mind  was  prepared  to  receive  the  new  evidence, 
and  to  put  it  to  the  proof  in  the  treatment  of  surgical 
cases.  It  is  impossible  for  us  now  to  realize  the  horrors 
and  the  mortahty  attached  to  surgical  work  at  the  period 
when  Pasteur's  papers  were  written.  In  almost  every 
case  the  discharge  from  a  wound  underwent  putrefaction; 
inflammation  of  varying  degrees  of  severity  attacked  the 
wounds,  pus  poured  from  their  surfaces,  and  hospital 


THE  MURPHY  MEMORIAL  ORATION  29 

gangrene,  erysipelas,  and  pyaemia,  the  most  desperate 
form  of  blood  poisoning,  occurred  with  terrible  frequency. 
The  clean  healing  of  a  wound  by  "first  intention"  rarely 
occurred.  A  surgeon  was  more  than  content,  he  was 
eager  and  gratified,  to  see  a  thick  creamy  discharge  of 
"laudable  pus"  from  the  surfaces  of  a  wound.  Very 
few  operations  were  performed,  and  then,  as  a  general  rule, 
only  in  cases  where  death  or  extreme  disabihty  was  other- 
wise certain.  Limbs  were  amputated  when  smashed,  or 
diseased  as  to  be  worthless  and  dangerous;  the  mortafity 
from  amputations  varied  from  40  to  50  per  cent.  In 
Lister's  hands,  up  to  the  year  1865,  in  15  cases  of  excision 
of  the  wrist-joint  by  his  own  method,  6  patients  suffered 
from  hospital  gangrene  and  1  died  from  pyaemia.  Volk- 
mann,  one  of  the  earhest  of  Lister's  disciples,  had  results 
so  ghastly  that  he  decided  to  close  his  hospital  altogether 
for  some  months.  Lister's  own  account  of  his  wards  at 
Glasgow  is  disturbing  and  distressing  even  today.  The 
most  vigorous  and  robust  patients  were  swept  away  after 
the  most  trifling  injuries  or  operations,  and  septic  diseases 
were  so  frequent  and  so  deadly  that  the  very  name  of 
hospital  was  dreaded  by  every  sufferer.  John  Bell,  a 
great  surgeon,  spoke  of  the  hospital  as  a  "house  of  death." 
In  the  paper  which  Lister  had  read,  Pasteur  asserted 
that  "the  most  far  reaching  of  my  researches  is  simple 
enough,  it  is  that  putrefaction  is  produced  by  hving 
ferments."  He  asserted  that  the  oxygen  of  the  air  was 
not  the  cause  of  putrefaction,  as  everyone  hitherto  had 
supposed;  that  indeed  some  of  the  causes  of  decomposition 
could  thrive  only  in  the  absence  of  oxygen.  This  ob- 
servation, which  distinguishes  "aerobic"  from  "anaerobic" 
organisms,  is  of  the  first  importance.  Lister  at  once 
reahzed  the  significance  of  this  work  in  connection  with  the 


30  ESSAYS  ON  SURGICAL  SUBJECTS 

changes  occurring  in  wound  discharges  and  on  wound 
surfaces.  In  1867  he  wrote:  "When  it  had  been  shewn 
by  the  researches  of  Pasteur  that  the  septic  property  of 
the  atmosphere  depended  not  on  the  oxygen  or  any 
gaseous  constituent,  but  on  minute  organisms  suspended 
in  it,  which  owed  their  energy  to  their  vitality,  it  oc- 
curred to  me  that  decomposition  in  the  injured  part 
might  be  avoided,  without  excluding  the  air,  by  applying 
as  a  dressing  some  material  capable  of  destroying  the  life 
of  the  floating  particles."  He  proceeded  to  make  trial 
of  the  hypothesis  in  his  own  work.  At  this  time  he  had 
heard  also  of  the  experiments  made  at  Carhsle  with  the 
disinfection  and  deodorization  of  sewage  by  German 
creosote,  a  crude  form  of  carboHc  acid.  The  administra- 
tion of  a  very  small  proportion  of  this  substance  not  only 
prevented  all  odour  from  the  lands  irrigated,  but  destroyed 
the  entozoa  which  usually  infest  cattle  fed  upon  such 
pastures.  This  was  the  preparation  he  decided,  after 
trying  chloride  of  zinc  and  the  sulphites,  to  rely  upon  in 
his  early  trials. 

Among  surgical  cases  then,  as  now,  the  sharpest 
distinction  was  drawn  between  simple  and  compound 
fractures;  between  fractures,  that  is,  where  the  soft  parts 
are  almost  unhurt  and  the  skin  unwounded,  and  frac- 
tures in  which  a  wound  through  the  skin  and  soft  tissues 
reaches  the  broken  ends  of  bone.  In  simple  fractures,  life 
was  rarely  or  never  in  jeopardy;  in  compound  fractures, 
putrefaction  of  wound  discharges  occurred,  septic  proc- 
esses became  rampant  and  the  mortality  was  high.  "The 
frequency  of  disastrous  consequences  in  compound  frac- 
tures, contrasted  with  the  complete  immunity  from  danger 
to  life  or  Umb  in  simple  fracture,  is  one  of  the  most 
striking  as  well  as  melancholy  facts  in  surgical  practice.'* 


THE  MURPHY  MEMORIAL  ORATION  31 

These  were  the  opening  words  of  Lister's  first  paper  on  the 
"new  methods"  in  the  Lancet  in  1867.  The  first  trial 
of  this  method  proved  disastrous  owing  to  improper 
management,  but  the  second  attempt,  on  August  12, 
1865,  proved  perfectly  satisfactory,  and  was  followed  by 
others  which  more  than  reahzed  Lister's  most  sanguine 
expectations.  Compound  fractures  healed  and  united  as 
easily  and  quickly,  and  almost  as  safely,  as  simple  frac- 
tures. The  method  proved  by  so  stern  a  trial  was  soon 
applied  to  cases  of  chronic  abscess,  and  by  degree  to  opera- 
tion wounds.  In  one  of  his  earher  papers  Lister  wTOte: 
"Admitting  then  the  truth  of  the  germ  theory  and  proceed- 
ing in  accordance  with  it,  we  must  when  dealing  with  any 
case  destroy,  in  the  first  instance,  once  for  all  any  septic 
organisms  which  may  exist  within  the  parts  concerned; 
and  after  this  is  done,  our  efiforts  must  be  directed  to  the 
prevention  of  the  entrance  of  others  into  it."  This  state- 
ment shews  that  Lister  laid  down  the  two  essential 
principles  of  antiseptic  system,  the  prophylactic  and  the 
therapeutic. 

Lister's  work,  it  is  evident,  was  the  result  of  research 
carried  out  both  by  the  inductive  and  by  the  deductive 
method,  and  tested  and  confirmed  by  many  experiments. 
He  combined  in  full  measure  the  wide,  patient,  penetrating 
inquiry,  the  comprehensive  generalization,  and  the  sound 
wisdom  of  the  method  of  Hippocrates,  with  the  demand 
for  experimental  illumination  or  proof  afforded  by  the 
method  of  Galen,  of  Bacon,  and  of  Harvey.  He  combined 
in  his  own  work  the  best  of  all  the  schools,  and  it  was  no 
accident  that  the  greatest  of  all  discoveries  relating  to  the 
science  and  the  art  of  surgery  was  made  by  him. 

If  a  man's  services  to  humanity  are  the  standard  by 
which  we  measure  his  value,  then  Lister  may  be  counted  £is 


52  ESSAYS  ON  SURGICAL  SUBJECTS 

perhaps  the  greatest  man  the  world  has  ever  produced. 
For  he  has  been  the  means  of  aboHshing,  or  assuaging, 
the  sufferings  of  men  and  women  to  a  degree  which  is 
quite  incalculable,  and,  as  I  said  of  him  years  ago,  he  has 
been  the  means  of  saving  more  lives  than  all  the  wars  of 
all  the  ages  have  thrown  away. 

As  the  result  of  Lister's  work  the  way  was  cleared  for 
an  immense  and  immediate  advance  in  surgical  practice, 
and  for  an  extension  into  regions  that  before  had  been 
denied  even  to  the  most  intrepid  surgical  adventure. 
The  result  is  known  to  all  the  world.  Diseases  which  were 
beyond  the  reach  of  any  are  now  within  the  grasp  of  all 
surgeons.  Operations  whose  mortahty  even  twenty-five 
years  ago  was  so  heavy  as  to  be  almost  prohibitive  are 
now  performed  with  a  frequency  and  with  a  degree  of 
safety  which  never  cease  to  excite  our  wonder.  But  Lis- 
ter's work  did  something  else;  it  shewed  how  research 
for  the  future  must  be  conducted  if  our  progress  were  to 
be  both  enterprising  and  safe.  It  shewed  that  clinical 
research  and  experiment  must  forever  run  together. 

The  achievements  of  chnical  research  have  been 
gigantic  since  Lister's  day.  The  safety  which  he  brought 
into  all  our  work  resulted  in  an  advancement,  httle  by 
little,  of  the  attack  upon  the  diseases  of  internal  organs, 
and  it  exercised  in  consequence  a  very  powerful,  germinal 
influence  upon  internal  medicine.  If  our  knowledge  of 
the  disease  of  the  abdominal  viscera  of  thirty  years  ago 
is  compared  with  that  of  today  the  truth  of  this  statement 
wiU  appear.  In  connection  with  the  diseases  of  the  gall- 
bladder and  bile-ducts  the  work  of  Courvoisier  published 
in  1890  is  a  complete  record :  it  is,  indeed,  one  of  the  most 
monumental  works  ever  produced  in  surgical  Hterature. 
What  was  known  then,  in  comparison  with  now  ?    Nothing 


THE  MURPHY  MEMORIAL  ORATION  33 

of  the  early  symptoms  of  gall-stones,  of  the  relation  be- 
tween them  and  visceral  and  other  infections,  nothing 
of  the  symptoms  due  to  the  impaction  of  stones  in  one  or 
other  of  the  ducts;  almost  nothing  of  the  possibihties  of 
safe  rehef  by  surgery.  Lister's  work  has  not  only  been 
the  means  of  relief  to  the  patient  in  his  agony,  but  has 
been  the  instrument  by  which  our  own  most  prolific  en- 
quiries into  the  symptomatology,  etiology,  and,  in  no  in- 
significant degree,  the  pathology  of  this  disease  has  been 
made.  Of  gastric  ulcer  as  distinguished  from  cancer  of 
the  stomach  our  knowledge  thirty  years  ago  was  trivial 
compared  with  what  it  is  today.  Much  of  the  teaching 
of  those  days  is  not  confirmed  by  the  surgical  enquiries 
of  today;  and  it  is  now  I  suppose  admitted  universally 
that  unless  the  physician  is  guided  by  the  principles  of 
diagnosis  discovered  by  the  surgeon  and  the  radiographer 
he  will  stray  wide  from  the  path  of  truth.  So,  too,  of 
duodenal  ulcer,  our  present  knowledge  of  which  is  due 
entirely  to  the  chnical  research  made  possible  by  safe 
surgery.  And  the  Hst  might  be  greatly  extended.  Much 
more  remains  to  be  done.  We  are  only  on  the  threshold 
of  our  enquiries  as  to  the  complementary  action  of  one 
organ  upon  another;  of  the  relations,  for  example,  of 
the  pancreas,  spleen,  and  liver  to  each  other;  and  of  all 
or  any  of  these  to  parts,  or  to  the  whole,  of  the  alimentary 
canal,  and  to  the  organs  possessed  only  of  an  internal 
secretion.  CHnical  research  involves  and  implies  the 
fullest  enquiry  into  the  detailed  character  of  all  present 
symptoms;  the  most  searching  pursuit  after  those  earliest 
departures  from  smooth  and  normal  action  which  observa- 
tion can  discover,  the  correlation  of  all  these  with  the 
manifest  changes  observed  at  all  stages  in  the  several 

organs  during  operations  upon  any  of  them.     When  all 
3 


3U  ESSAYS  ON  SURGICAL  SUBJECTS 

this  knowledge  has  slowly  and  patiently  been  garnered, 
then  the  method  of  experiment  must  be  used  to  carry  our 
enquiries  still  further,  and  to  help  us  to  answer  the  ques- 
tion:  "How  do  these  things  happen?"     CHnical  research 
will  tell  us  of  the  changes  in  other  organs  associated  with 
the  one  to  which  our  main  enquiry  is  directed,  but  a 
process  of  deduction  and  an  enquiry  by  experiment  are 
necessary  before  we  can  disclose  the  sequence  of  events 
which  culminate  at  last  in  the  disease  we  set  out  to  study. 
The  chnical  research,  is  beyond  question,  the  more  arduous. 
The  factors  which  enter  into  it  are  so  many,  so  variable,  so 
impressed  by  the  changing  conditions  and  moods  and 
circumstances  of  the  patient  that  only  the  most  inde- 
fatigable patience  and  the  most  trained  capacity  can  help 
to  resolve  the  matter  into  simple  terms,   to  dissociate 
what  may  be  an  infinitely  complex  grouping  of  many 
facts  before  we  can  rearrange  them  in  appropriate  sequence 
of  process  or  of  time.    We  must  discover  the  "usual 
conditions,"  obtain  our  general  notions,  observe  carefully 
a  multitude  of  facts,  arrange  them  in  orderly  fashion, 
employ  the  mental  act  which  will  bring  them  together 
as  elements  in  a  great  truth.    When  this  is  done,  and  only 
when  this  is  done,  can  the  deductive  method  of  Galen 
be   employed   to  fullest  advantage.    Experimental   re- 
search is  not  so  baffling  a  task.     Great  ingenuity  in  the 
devising  of  experiments  may  be  found  in  the  supreme 
masters,  Pawlow,  Almroth  Wright,  and  a  very  few  others. 
But  each  experiment  often  contains  only  the  one  question 
to  which  the  answer  is  sought.     The  answer  is  "yes"  or 
"no,"  or  is  expressed  in  simple  terms,  and  it  is  free  from 
those  infinite  perplexities  and  changing  proportions  which 
distinguish  the  answer  given  to  any  enquiry,  even  the 
simplest,  in  the  method  of  clinical  research.    When  in  a 


THE  MURPHY  MEMORIAL  ORATION  35 

simple  experiment  the  answer  is  given,  a  new  problem  may 
arise  suggesting  a  tother  experiment.  Thus  a  chain  of 
experiments  may  develop  each  of  which  answers  not  only 
its  own  question,  but  contributes  in  its  own  degree  to  the 
final  answer  embracing  the  entire  sequence  of  experiments. 
The  single  experiment  may  be  simple.  But  in  respect  of  a 
series,  each  member  of  which  is  dependent  upon  its 
predecessor,  and  provokes  its  successor,  and  all  of  which 
illuminate  or  decide  some  problem  suggested  by  chnical 
research,  nothing  has  been  done  in  surgery  comparable 
to  that  which  in  chemistry  has  been  achieved  by  Fisher 
and  Abderhalden. 

These  brief  glimpses  at  the  progress  of  surgery  shew 
that  its  epochs  may  be  considered  as  three  in  number. 

In  the  first  and  longest  the  writings  of  Hippocrates 
and  Galen  were  regarded  as  an  inspired  gospel.  By  them 
the  minds  of  men  were  held  captive,  and  their  imagination 
enslaved,  and  every  new  adventure  in  thought  or  action 
suppressed  or  cramped.  To  seek  in  them  for  knowledge 
was  all  the  effort  of  every  man.  What  was  written  in 
them  was  truth,  what  was  outside  them  rank  heresy. 
Where  the  meaning  was  not  as  plain  as  day  the  most 
endless  enquiry  and  discussion  ensued.  The  controversies 
which  then  shook  the  intellectugd  world  to  its  very  founda- 
tion are  seen  now  to  be  only  laughable,  both  in  their 
methods  and  in  their  quaint  decisions.  In  later  ages  to 
challenge  the  truth  or  the  final  revelation  of  any  teaching 
of  Galen's  was  almost  blasphemous,  and  it  required  a  rare 
and  reckless  courage  to  say,  as  did  Henry  of  Mondeville, 
"God  did  not  surely  exhaust  all  his  creative  power  in 
making  Galen."  The  prophets  and  seers,  who  Httle  by 
httle,  and  with  very  needful  caution,  led  the  world  through 
this  black  night,  death's  second  self,  into  the  dawn,  were 


36  ESSAYS  ON  SURGICAL  SUBJECTS 

the  anatomist  Mondinus,  Vesalius,  Fabricius,  Fallopius, 
and  others.  By  their  work  the  assertions  of  the  old 
scriptures  could  be  openly  gauged.  In  gross  anatomy  a 
structure  stands  out  for  all  to  see.  If  Galen's  teaching 
denied  the  truth  disclosed  by  dissection  it  was  most  gently 
and  tentatively  refuted,  heretical  and  perilous  as  such  a 
work  might  be.  And  as  normal  anatomy  grew  it  was 
joined  by  morbid  anatomy,  and  at  last  came  Morgagni 
and  Hunter.  They  established  the  second  great  era  in 
which  the  pathology  of  the  dead  was  studied  with  a 
wealth  of  care  and  inexhaustible  patience.  The  gross 
lesions  of  morbid  anatomy,  and  even  many  that  were 
recondite  and  remote,  were  examined,  described,  dis- 
cussed, and  arranged  in  due  order  by  a  mighty  succession 
of  able  men,  whose  work  today  we  too  Hghtly  neglect. 
Clinical  medicine  and  surgery  were  dominated  by  the 
knowledge  of  the  morbid  processes  discovered  in  this  time. 
Symptoms  were  correlated  with  the  signs  found  upon  the 
postmortem  table  and  upon  the  shelves  of  museums. 
Chnical  histories  were  largely  devoted  to  terminal  con- 
ditions, for  it  was  only  these  that  brought  a  patient  to  a 
hospital  where  he  died,  and  where  an  autopsy  could  be 
made.  But  patients  do  not  die  in  hospital  from  the  dis- 
eases from  which  they  suffer  long  during  life.  And  in 
consequence  severe  Hmitations  were  set  to  our  knowledge 
of  disease  of  all  kinds. 

Lister's  work  made  possible  the  third  era  which  de- 
pended for  its  swift  and  notable  advance  upon  a  study  of 
the  pathology  of  the  Hving,  upon  a  study,  that  is,  of 
morbid  processes  in  their  course  rather  than  when  their 
race  was  fully  run.  By  multiplying  observations  made 
during  operations  we  learnt,  httle  by  httle,  how  to 
capture  a  general  truth  from  a  series  of  individual  exam- 


THE  MURPHY  MEMORIAL  ORATION  37 

pies.  By  slow  degrees  and  grudgingly  it  was  admitted 
that  terminal  manifestations  of  disease  and  the  advanced 
ravages  of  morbid  anatomy  did  not  constitute  all  medi- 
cine; that  earlier  symptoms  were  to  be  referred  to  earlier 
changes  in  organs  exposed  during  the  course  of  operations. 
And  these  changes  and  symptoms  we  now  reahze  are 
themselves  but  late;  still  earlier  manifestations  of  aber- 
rant action  are  being  sought  patiently  and  with  a  success 
that  holds  increasing  hope  for  future  work. 

During  all  these  three  periods,  through  Galen,  Vesahus, 
Harvey,  Bacon,  Hunter,  Lister,  there  has  run  a  vein  of 
experimental  work,  testing  hypothesis  and  discovering 
new  truths.  Since  Lister's  day  there  has  been  a  steadily 
increasing  recognition  of  the  value  of  such  work  and  of 
the  urgent  necessity  of  continuing  it,  of  enlarging  its  field 
so  that  it  may  be  coterminous  with  medicine  itself.  We 
are,  indeed,  newly  entered  upon  another  stage,  the  stage 
of  combined  research,  in  which  clinical  observation,  in- 
ductive and  deductive  processes  of  reasoning,  and  ex- 
perimental enquiry  are  Unked  together.  In  its  progress, 
so  far,  the  work  of  a  few  men  stands  out  as  of  the  utmost 
significance.  Horsley's  work  upon  myxoedema,  cretinism, 
and  on  the  functions  of  the  thyroid  gland;  Ferrier's, 
Macewen's,  and  Horsley's  researches  upon  cerebral  affec- 
tions and  cerebral  locahzation;  Senn's  work  upon  the 
pancreas  and  upon  the  intestines;  Kocher's  work  upon 
cerebral  compression  and  upon  the  thyroid  gland;  Crile's 
work  upon  shock  and  upon  blood  transfusion ;  and  Harvey 
Cushing's  work  upon  diseases  of  the  brain  and  the  pitui- 
tary gland.  Since  Lister  rid  all  operations  upon  man  and 
upon  animals  of  their  former  terrors,  many  surgeons  have 
turned  to  experiment  in  order  to  perfect  and  to  illustrate 
their  own  work,  to  test  an  hypothesis,  to  search  for  new 


38  ESSAYS  ON  SURGICAL  SUBJECTS 

procedures  or  to  discover  an  explanation  of  clinical 
phenomena  whose  meaning  was  difficult  to  unravel.  In 
recent  days  few  men  have  displayed  so  vast  a  range  of 
clinical  interests,  so  keen  a  zest  for  relevant  experimental 
enquiry,  so  logical  a  mind,  such  frank  intellectual  honesty 
as  Murphy.  He  may  justly  be  ranked  as  one  of  the 
earliest  and  one  of  the  greatest  exponents  of  the  method  of 
combined  research. 

Murphy's  first  work  to  attract  the  attention  of  all 
surgeons  was  that  which  led  him  to  devise  and  to  perfect 
the  most  exquisite  surgical  implement  that  has  ever  been 
invented,  "Murphy's  button."  Up  to  the  time  at  which 
experimental  work  on  the  anastomosis  of  hollow  abdominal 
viscera  was  begun  by  Senn,  Murphy,  and  others,  the 
method  of  securing  union  was  difficult,  tedious,  and  un- 
safe. I  well  remember  to  have  seen  the  operation  of 
"pylorectomy"  done  in  the  year  1889.  A  very  niggardly 
removal  of  a  small  "prepyloric"  carcinoma  was  made,  and 
the  cut  end  of  the  duodenum  was  united  to  a  part  of  the 
divided  end  of  the  stomach  after  the  first  method  of  Bill- 
roth. We  counted  over  two  hundred  sutures  used  to 
effect  the  junction.  Each  suture  was  of  silk;  for  each  the 
needle  was  separately  threaded,  the  suture  passed,  tied, 
and  cut;  a  wearisome  total  of  movements  of  the  surgeon 
and  his  assistants,  involving  a  great  expenditure  of  time. 
No  wonder  the  surgeons  searched  for  simpler  methods. 
Senn's  bone  plates,  the  first  mechanical  apparatus  to 
assist  in  an  anastomosis,  were  ingenious  instruments  not 
very  easy  to  use,  requiring  a  not  inconsiderable  degree 
of  skill  and  patience  to  secure,  that  the  threads  holding 
them  were  well  and  truly  tied,  and  calHng  also  for  the 
introduction  of  a  number  of  additional  sutures.  The 
results  following  the  use  of  these  instruments  were  some- 


THE  MURPHY  MEMORIAL  ORATION  39 

times  very  good  and  sometimes  very  bad.     While  surgeons 
were  struggling  with  this  tiresome  and  unsatisfactory 
implement,  Murphy  introduced  his  "button."     It  was 
the  result  of  a  great  deal  of  experimental  work  done  upon 
dogs,  in  the  early  hours  of  the  morning,  and  in  the  lean 
years  of  his  early  married  Ufe.     In  this  work  Mrs.  Murphy 
took  her  share,  giving  chloroform  to  the  animals.    A  few 
people  were  privileged  to  know  of  the  boundless  help  and 
inspiration  which  Mrs.  Murphy  gave  her  husband  in  those 
hard,  but  happy  days  when  he  was  struggling  for  his  place 
in  the  world  of  surgery.     His  wonderful  success  was  in  no 
small  way  due  to  her  sympathy,  encouragement,  £uid  un- 
faltering behef  in  him;  and  to  the  eager  enthusiasm  which 
she  shewed  in  all  his  work.    His  fame  was  her  fame  also. 
As  I  offer  to  him  my  tribute  of  laurel  for  honour  and  of 
rosemary  for  remembrance,  it  is  an  added  pride  that  I  can 
do  so  in  her  presence.     With  the  help  of  Murphy's  button 
operations  which  had  been  difficult  and  perilous  at  once 
became  so  simple  that  the  merest  tyro  could  perform  them, 
and  the  risk  of  all  operations  fell  with  amazing  rapidity. 
The  button  was  used  in  every  cUnic  and  upon  all  occa- 
sions where  visceral  anastomoses  had  to  be  effected;  and 
the  name  and  the  fame  of  Murphy  travelled  round  the 
world.    But  I  still  think  that  the  great  virtue  of  the 
button  was  not  in  its  own  direct  use,  but  in  the  convincing 
demonstration  it  gave  to  us  of  the  essential  simplicity 
of  the  process  of  visceral  union.     By  using  the  button  we 
learned  how  safely  and  how  rapidly  the  peritoneal  junc- 
tion took  place;  there  was  no  need,  it  was  now  perfectly 
evident,  for  the  hundreds  of  stitches  that  all  surgeons 
were  using.     Firm,  even  approximation  for  a  very  few 
days  would  lead,  the  button  showed  beyond  a  doubt,  to  a 
permanent  and  secure  fusion  of  the  apposed  viscera. 


40  ESSAYS  ON  SURGICAL  SUBJECTS 

The  button  itself  was  occasionally  a  danger.  After  the 
operation  of  gastro-enterostomy  it  sometimes  remained 
for  many  months  in  the  stomach ;  when  it  passed  on  to  the 
lower  intestine  it  might  cause  obstruction,  or  it  might 
ulcerate  its  way  through  the  intestinal  wall.  We  learned 
from  the  use  of  the  button  not  that  the  button  itself 
should  be  used,  but  all  the  secrets  of  the  principles  of 
entero-anastomosis.  It  is  not  the  least  exaggeration  to 
say  that  Murphy  revolutionized  the  methods  of  visceral 
anastomosis,  and  was  partly  responsible  for  giving  that 
impulse  to  abdominal  surgery  which  in  later  years  has 
carried  it  so  far. 

A  characteristic  example  of  his  method  of  approach- 
ing a  surgical  subject  to  which  he  desired  to  contribute 
is  shewn  in  his  work  on  "Ankylosis,"  which  he  began 
in  1901.  Up  to  that  time  the  treatment  of  stiff  joints 
was  unsatisfactory,  and  in  cases  of  severe  ankylosis, 
whether  bony  or  densely  fibrous,  was  almost  hopeless. 
Murphy  says  he  proposes  to  begin  the  study  of  his  subject 
by  some  questions:  "What  are  joints?  What  is  the 
embryology  of  joint  formation?  What  is  the  pathological 
histology  of  aquired  arthoses,  of  false  joints?  What  is  the 
pathology  of  hygromata?  (acquired  endothehal  fined  sac) 
Can  they  be  produced  artificially?  What  is  ankylosis? 
What  are  the  pathologic  and  anatomic  changes  included 
in  the  term?  What  tissues  are  involved?  From  a 
practical  standpoint,  into  what  classes  may  it  be  divided? 
When  ankylosis  has  formed,  what  are  the  limitations  of 
surgery  for  its  refief?  Can  we  re-establish  a  movable, 
functionating  joint  with  synovial  lining?  Can  we  restore 
motion,  and  to  what  degree?  In  what  class  of  cases  can 
the  best  results  be  secured?    Can  we  for  the  future 


THE  MURPHY  MEMORIAL  ORATION  Ul 

promise  better  than  the  flexible,  fibrous  unions  that  we 
have  secured  in  the  past?'* 

He  then  discusses  the  development  of  joints  in  the 
embryo,  and  the  method  of  bursa  formation  in  early  and 
in  adult  fife,  shews  that  hygromata  and  ganglia  are  the 
products  of  the  liquefaction  of  hypertrophied  connec- 
tive tissue,  and  indicates  that  in  an  artificial  development 
of  joints  all  the  facts  relative  to  these  processes  should  be 
utihzed.  The  formation  of  "false  joints"  as  a  result  of 
non-union  in  fractures  of  the  long  bones  led  to  the 
recognition  of  the  pathological  condition  whose  counter- 
part was  provoked  in  the  operation  of  arthroplasty,  in 
which  a  foreign  body  was  inserted  between  the  end  of 
bones  separated  at  an  ankylosed  joint,  to  prevent  re- 
union and  to  cause  the  development  of  a  new  joint.  He 
then  investigates  the  matter  by  experiments  upon  dogs, 
and  proceeds  to  demonstrate  its  efficacy  upon  men 
afflicted  by  bony  ankylosis  of  their  joints.  The  whole 
piece  of  work  is  an  exemplary  instance  of  the  combination 
of  clinical  experience  and  of  experimental  research  leading 
to  the  establishment  of  a  new  method  of  treatment  in  a 
severe  and  most  disabfing  condition. 

In  1897,  Murphy  pubhshed  his  article,  "Resection  of 
Arteries  and  Veins  Injured  in  Continuity.  End-to-End 
Suture;  Experimental  and  Chnical  Research,"  in  which 
for  the  first  time  he  estabhshed  the  principles,  and 
described  one  of  the  methods,  of  arterial  suture  and 
anastomosis.  As  in  other  articles,  chnical  needs  indicate 
the  fines  of  his  experimental  enquiries;  and  a  widening  of 
the  bounds  of  surgical  endeavour  and  practice  is  the  result. 
In  1898,  he  defivered  at  Denver  the  Oration  on  Surgery 
before  the  American  Medical  Association  and  chose  as 
his  subject  the  "Surgery  of  the  Lungs."     Independently 


42  ESSAYS  ON  SURGICAL  SUBJECTS 

of  Forlanini  he  suggested  the  injection  of  nitrogen  into 
the  pleural  cavity  in  cases  of  hopeless  unilatergd  disease 
of  the  lung.  No  enthusiastic  acceptance  greeted  the 
suggestion.  Murphy  himself  extended  the  method  in  his 
later  work  to  cases  of  incipient  tuberculous  disease ;  and 
recent  experience  has  fully  justified  all  his  claims  and  has 
given  sanction  to  his  methods.  He  again  combined 
clinical  experience  and  research  by  experiment  in  his 
work  on  "Surgery  of  the  Spinal  Cord,"  pubHshed  in  1907, 
and  his  final  summary  on  neurological  surgery  in  Surgery, 
Gynecology,  and  Obstetrics,  1907,  iv,  385,  was  the  most 
accurate  and  concise  survey  of  our  knowledge  of  this  sub- 
ject which  had  then  been  pubHshed. 

Wherever  we  turn  we  find  his  method  to  be  the  same. 
A  wide  survey  of  the  subject  to  be  discussed  made  in- 
teresting by  the  personal  magic  that  he  was  able  to  throw 
into  it;  a  disclosure  of  the  gaps  in  our  knowledge;  a  sug- 
gestion as  to  the  means  by  which  that  knowledge  or  a 
want  in  our  technical  methods  can  be  made  good ;  a  record 
of  experiment  to  elucidate  or  to  solve  a  difiicult  point; 
a  wealth  of  cHnical  observation  and  a  formidable  array 
of  arguments,  lead  to  an  inevitable  conclusion  stated  in 
terms  that  none  could  fail  to  comprehend.  In  every 
article  of  his  that  we  read  we  can  see  the  working  of  an 
orderly  mind,  of  a  mind  most  eager  for  new  truths,  and 
expectant  of  them.  For  every  subject  he  seems  to  have  a 
mental  scaffolding  by  which  he  guides  and  arranges  the 
truths  as  they  are  fashioned  and  duly  laid  in  place.  He 
had  a  zeal  for  classifications  which  looked  complex,  but 
when  carefully  considered  tended  to  simpficity  and  to 
easy  and  ready  remembrance.  Of  his  other  surgical 
work  and  of  his  high-minded  endeavour  to  seek  for  and  to 
secure  the  purity  and  advancement  of  his  own  profession 


THE  MURPHY  MEMORIAL  ORATION  ^ 

I  need  say  nothing.  It  is  a  record  of  sincere  and  honest 
devotion  to  his  duty  as  he  saw  it  before  him.  Great 
deeds  are  born  of  great  zeal  and  high  resolve;  and  he  was 
lacking  in  neither.  All  that  he  did  is  within  the  recent 
memory  of  his  colleagues  here.  My  immediate  purpose 
has  been  fulfilled  if  I  have  sketched,  however  roughly, 
the  giant  figure  of  the  man  and  the  surgeon  whose  work 
was  done  among  you  and  whose  fame  has  spread  out  into 
all  lands. 

Our  calKng  by  common  consent,  the  noblest  of  any, 
dignifies  all  who  join  its  ranks.  The  honour  of  the  pro- 
fession is  the  cumulative  honour  of  all  who  both  in  days 
gone  by  and  in  our  own  time  have  worthily  and  honestly 
laboured  in  it.  In  every  generation  there  are  a  chosen 
happy  few  who  shed  a  special  lustre  upon  it  by  their 
character,  their  scientific  attainments,  or  the  great  glory 
of  their  service  to  their  fellow  men;  for  it  is,  as  Ambrose 
Pare  said,  "beautiful  and  the  best  of  all  things  to  work 
for  the  refief  and  cure  of  suffering."  In  our  generation 
Murphy  was  one  who  by  his  full  devotion,  his  complete 
surrender  to  its  ideals,  and  by  his  loyal,  earnest,  and  un- 
ceasing work,  added  distinction  to  our  profession,  which, 
in  return,  showered  upon  him  the  rewards  with  which  no 
others  can  compare,  the  approbation  of  his  fellow  workers 
and  the  friendship  and  trust  of  the  best  among  his  con- 
temporaries in  every  country. 

"The  mightier  man,  the  mightier  is  the  thing 
That  makes  him  honom'ed." 

As  we  look  backward  upon  the  long  history  of  the 
science  and  art  of  medicine  we  seem  to  see  a  great  proces- 
sion of  famous  and  heroic  figures,  each  one  standing  not 
only  as  a  witness  of  his  own  authentic  achievements,  but 


44  ESSAYS  ON  SURGICAL  SUBJECTS 

also  as  a  symbol  of  the  traditions,  ideals,  and  aims  of 
the  age  which  he  adorns.  The  procession  is  sometimes 
thinly  stretched  out,  or  even  rudely  broken  here  and  there, 
but  in  happier  ages  it  is  thronged  by  an  eager  and  exult-, 
ant  crowd.  In  medicine  the  whole  pageant  is  as  noble 
and  splendid  as  in  any  of  the  sciences  or  arts,  and  it 
reveals  the  collective  and  continuous  genius  of  a  band  of 
men  inspired  by  the  loftiest  purpose,  and  lavish  in  labour 
and  sacrifice  for  the  welfare  of  mankind.  They  have 
come  throughout  the  ages  from  every  land.  They  now 
belong  not  to  one  country  but  to  every  country,  for  they 
are  the  common  possession  and  the  pride  of  all  the  world. 
They  have  lost  their  nationahty  in  death.  They  are 
men  whose  deeds  will  not  be  forgotten  and  whose  names 
will  live  to  all  generations.  Among  such  men,  few  in 
number,  supreme  in  achievement,  John  Benjamin  Miu-- 
phy  is  worthy  to  take  his  place. 


THE  RITUAL  OF  A  SURGICAL  OPERATION* 

Every  operation  in  surgery  is  an  experiment  in  bac- 
teriology. The  success  of  the  experiment  in  respect  of 
the  salvation  of  the  patient,  the  quality  of  heahng  in  the 
wound,  the  amount  of  local  or  constitutional  reaction, 
the  discomforts  during  the  days  following  operation,  and 
the  nature  and  severity  of  any  possible  sequels,  depend 
not  only  on  the  skill  but  also  upon  the  care  exercised  by 
the  surgeon  in  the  ritual  of  the  operation.  The  "ritualist" 
must  not  be  a  man  unduly  concerned  with  fixed  forms 
and  ceremonies,  with  carrying  out  the  rigidly  prescribed 
ordinances  of  the  surgical  sect  to  which  he  owes  allegiance; 
but  a  man  who,  while  observing  with  unfaltering  loyalty 
those  practices  which  experience  and  experiment  have 
together  imposed  upon  him,  refuses  to  be  merely  a 
mimic  bound  by  custom  and  routine.  He  must  set 
endeavour  in  continual  motion,  and  seek  always  and 
earnestly  for  simpler  methods  and  a  better  way.  In  the 
craft  of  surgery  the  master  word  is  simpHcity. 

The  ritual  of  an  operation  commences  before,  some- 
times long  before,  the  incision  is  made,  and  may  continue 
for  a  long  period  after  the  wound  is  healed.  In  the  transi- 
tion of  a  patient  from  ill  health  to  sound  health  the  opera- 
tion itself  is  only  one — though  it  may  be  the  most  im- 
portant— of  all  the  factors  concerned  in  this  fortunate 
event. 


*  Remarks  made  at  the  opening  of  a  discussion  at  the  first  meeting  of  the 
British  Association  of  Surgeons,  held  at  the  Royal  College  of  Surgeons,  May  14, 
1920.    Reprinted  from  The  British  Journal  of  Surgery,  Vol.  VIII,  No.  29,  1920. 


^6  ESSAYS  ON  SURGICAL  SUBJECTS 

In  this  discussion  we  are  not  asked  to  deal  with  two 
essential  preliminary  propositions,  the  necessity  for  the 
most  careful  clinical  inquiry  into  all  aspects  of  the  patient's 
history  and  condition,  so  that  accuracy  of  diagnosis  may 
be  achieved  before  operation;  and  the  exact  relevance  of 
the  proposed  operation  in  the  particular  conditions  rec- 
ognized by  this  inquiry,  or  discovered  during  the  course 
of  the  operation  itself.  A  great  many  mistakes  are  still 
made  in  both  these  matters.  It  is  useless,  to  say  the  least, 
to  perform  the  most  perfect  technical  operation  in 
conditions  which  do  not  call  for  it;  and  the  test  of  a 
successful  operation  is  not  restricted  to  the  heahng  of 
the  wound,  but  to  the  ultimate  effects  of  the  procedure 
upon  the  disorder  of  the  patient. 

When  conducting  our  experiment  in  bacteriology  we 
must  recognize  that  micro-organisms  capable  of  causing 
the  direst  disaster  may  possibly  be  everywhere — in  the  air, 
on  the  hands,  instruments,  gauze,  catgut,  etc.,  which  may 
be  introduced  into  the  wound,  or  upon  the  surface  of  the 
patient's  body.  The  possibility  of  the  patient's  own 
tissues  furnishing  a  septic  organism  is  so  remote  that 
we  may  leave  it  out  of  account  entirely.  It  is  an  excuse 
to  condone  rather  than  a  reason  to  explain  the  occurrence 
of  infection. 

Our  bacteriological  experiment  may  be  conducted  with 
one  of  two  intentions:  (1)  The  exclusion  of  all  organisms 
from  the  wound;  (2)  the  destruction  of  all  organisms 
reaching  the  wound,  by  a  bactericide  appKed  to  the  wound 
surfaces. 

It  is  not  accurate  to  speak  of  these  two  methods  as 
those  of  "aseptic"  and  "antiseptic"  surgery;  for  to  speak 
strictly  there  is  no  "aseptic"  surgery.  In  every  operation 
some  antiseptic  is  used  on  the  surgeon's  hands  or  the 


THE  RITUAL  OF  A  SURGICAL  OPERATION  Ul 

patient's  skin.  The  terms  are  accurate  enough  if  they 
are  held  to  apply  only  to  that  part  of  the  operation  which 
begins  with  the  incision  of  the  skin.  After  this  point  the 
use  of  antiseptics  in  a  "clean"  case  is  rarely  necessary, 
is  often  undesirable,  and  is  almost  always  of  greater  harm 
than  benefit.  It  is  to  insult  tissues  and  to  doubt  them, 
when  it  would  be  better  to  trust  their  very  considerable 
powers  of  self-defence. 

In  speaking  of  the  results  of  an  operation  a  surgeon 
may  be  a  prejudiced  witness  as  to  his  own  efforts,  and  a 
bad  judge  of  his  own  merit.  When  we  speak,  for  example, 
of  "heahng  by  first  intention,"  what  do  we  mean?  What 
is  our  standard?  Let  us  take  extreme  examples.  In  the 
one  we  mean  a  wound  which  heals  within  a  few  days, 
leaving  a  thin,  straight,  narrow  line  of  palest  pink. 
Around  this  hue  and  the  stitch-marks  everything  appears 
*'cold."  There  is  no  redness,  no  swelling,  no  stiffness  or 
induration,  and  at  the  Hne  itself  the  most  accurate 
apposition  of  skin  edges  is  seen.  There  is  no  discharge 
from  the  wound.  There  has  been  neither  local  nor 
constitutional  reaction  following  the  operation.  In  the 
other,  we  mean  a  wound  which  is  anything  but  straight; 
the  edges  are  jagged,  they  do  not  meet  accurately  at 
every  part,  they  overlap  here  and  there;  the  line  of  healing 
is  broad  and  irregular,  raised  and  red,  a  sticky  discharge 
oozes  from  the  unapposed  surfaces,  and  a  scab  may  he 
where  this  discharge  has  dried.  The  parts  around  are 
raised,  tender,  doughy,  or  stiff.  The  stitches  seem  to 
sink  into  the  skin.  You  may  see  wounds  of  this  kind  in 
some  chnics,  and  hear  a  complacent  conunent  that  the 
wound  has  healed  by  "first  intention."  Such  wounds  are 
the  clearest  evidences  either  of  a  bad  technique  or  of  a 
clumsy  operator,  or  perhaps  of  both.     If  we  had  a  Dr. 


4«  ESSAYS  ON  SURGICAL  SUBJECTS 

Johnson  in  our  profession,  and  he  were  asked  his  opinion 
of  such  wounds,  what  would  he  thunder  in  reply?  We 
know  what  he  said  when  pressed  for  his  opinion  of  a  young 
lady's  verses:  "Why,  they  are  very  well  for  a  young 
miss's  verses;  that  is  to  say,  compared  with  excellence, 
nothing;  but  very  well  for  the  person  who  wrote  them." 

In  every  discussion  it  is  necessary  for  the  protagonists 
to  agree  as  to  definitions  and  the  exact  meaning  to  be 
attached  to  words;  otherwise  polemics  are  valueless.  We 
must  here  discriminate  between  "perfect"  and  "imperfect" 
healing,  though  both  may  be  classed  as  examples  of  heahng 
by  "first  intention."  It  is,  moreover,  not  only  a  question 
of  the  healing  of  the  superficial,  visible  wound  which  is 
our  concern.  With  the  two  types  of  wound  heahng  I 
have  described  there  are  associated  not  only  the  varying 
chances  of  life  or  death  but  also  two  types  of  convales- 
cence, especially  in  abdominal  cases.  In  the  former  the 
patient  suffers  hardly  at  all,  indeed,  as  a  rule,  not  at  all, 
unless  there  have  been  great  technical  difficulties  in  the 
operation  itself,  such  as  remoteness  of  the  parts  concerned 
in  a  very  stout  subject. 

For  example  may  be  quoted  an  operation  for  chole- 
Hthiasis,  in  a  very  fat  woman,  when  the  Hver  hes  high, 
and  the  gall-bladder  is  small,  bound  up  in  dense  adhe- 
sions, fixed  to  the  duodenum  (perhaps  with  a  fistula  into 
it)  and  the  back  of  the  abdomen.  The  hver  and  costal 
margin  may  need  to  be  held  up,  and  the  abdominal  vis- 
cera to  be  dragged  downwards,  before  the  sclerosed  gall- 
bladder or  a  dilated  conmion  duct  containing  a  stone  can 
be  seen.  I  know  nothing  in  surgery  which  approaches 
such  cases  in  difficulty,  or  which  requires  such  care,  gen- 
tleness, patience,  and  skill  on  the  part  of  a  surgeon.  I 
sometimes  hear  the  operation  for  the  removal  of  a  Gas- 


THE  RITUAL  OF  A  SURGICAL  OPERATION         lt9 

serian  ganglion  or  the  avulsion  of  its  sensory  root  spoken 
of  as  "difficult."  It  is  work  for  a  novice  compared  with 
that  in  many  a  gall-bladder  case.  Apart  from  cases  such 
as  these,  which  require  firm  handhng,  the  amount  of  reac- 
tion is  negligible.  More  than  half  the  abdominal  cases, 
except  for  a  little  flatulence,  hardly  realize  that  they 
have  had  an  operation  performed.  Flatulence  is  a  trou- 
blesome complication  not  only  of  abdominal,  but  of  other 
operations  also.  Its  cause  is  uncertain.  My  own  view  is 
that  it  chiefly  results  from  the  starvation  and  purgation 
which  are  almost  universally  considered  a  necessary  part 
of  the  ritual  of  deliberate  operations.  Both  are  certainly 
undesirable,  and  are  possibly  harmful.  Sohd  food  is 
much  like  liquid  food  by  the  time  it  gets  well  on  its  way 
in  the  jejunum.  As  much  fluid  as  the  patient  wishes  to 
have  should  be  allowed  to  within  an  hour  or  two  of  the 
time  arranged  for  any  operation,  and  as  soon  as  possible 
afterwards.  Operations  on  the  stomach  are  no  exception. 
An  enema  generally  clears  the  colon  quite  as  much  as  is 
necessary.  Aperients  increase  the  number  and  the  viru- 
lence of  the  intestinal  micro-organisms,  and  are  apt  to 
deprive  the  patient  of  large  amounts  of  fluid  and  to  cause 
exhaustion :  efi'ects  which  are  all  most  undesirable. 

With  the  latter  kind  of  wound  just  described  there  is  a 
far  greater  general  reaction  and  a  higher  degree  of  discom- 
fort or  of  pain,  and  there  is  a  greater  likelihood  of  compli- 
cations, grave  or  trivial,  such  as  phlebitis,  thrombosis,  the 
late  discharge  of  buried  ligatures  or  sutures,  or  the  recuTr 
rence  of  the  condition  which  originally  required  operation. 

Surgery  should  be  a  merciful  art.  The  cleaner  and  the 
gentler  the  act  of  operation,  the  less  the  patient  suffers, 
the  smoother  and  the  quicker  his  convalescence,  the  more 
exquisite  his  healed  wound,  and  the  happier  his  memory 


v^ 


50  ESSAYS  ON  SURGICAL  SUBJECTS 

of  the  whole  incident,  to  him  probably  one  of  the  most 
important  in  his  life.  The  results  of  our  ritual  are  there- 
fore expressed  not  only  in  the  mortahty — where  the  differ- 
ence may  be  slight — but  also  in  the  quality  of  the  healing 
of  the  wound,  and  in  the  quahty  of  the  recovery  from 
the  operation,  in  respect  of  security,  rapidity,  smoothness, 
completeness,  and  finahty. 

In  the  ritual  of  a  surgical  operation  the  mysteries  are 
imposed  not  only  upon  the  high  priest  and  upon  the 
acolytes,  but  upon  the  congregation  also.  Every  visitor 
to  an  operation  theatre  takes  a  part,  however  remote,  in 
the  operation.  He  is  gowned,  masked,  and  his  head  cov- 
ered with  a  cap  nowadays  in  all  cUnics.  But  dirty  boots 
and  soiled  trouser  legs,  conveying  mud,  dust,  and  faecal 
matter  from  the  streets,  are  often  unnoticed.  If  the 
wearer  of  them  moves  about  the  theatre  freely,  or  goes 
from  one  theatre  to  another,  the  organisms  carried  in  the 
drying  filth  are  scattered  broadcast,  as  the  simplest  ex- 
periment will  prove.  Large  canvas  overalls  for  the  boots 
and  the  lower  part  of  the  leg,  tying  just  below  the  knee, 
as  a  sort  of  legging,  will  afford  ample  and  secure  covering 
to  this  possible  source  of  infection. 

The  surgeon  and  his  assistants  (the  fewer  the  better) 
should,  of  course,  change  all  their  external  garments  before 
operation.  The  trousers  and  coats  we  all  wear  are  very 
dirty.  What  would  a  pair  of  tennis  flannels  look  Uke  at 
the  end  of  a  week's  wear  in  London  .^^  Our  everyday 
darker  garments  do  not  show  the  same  marks,  but  they 
carry  the  same  dirt.  White  sterilized  trousers,  clean 
white  shoes  or  overshoes,  sterile  coat,  cap  and  mask,  all 
are  necessary  for  the  perfect  outfit.  They  are  much  more 
comfortable  to  wear  in  a  theatre  adequately  warmed,  and 
there  is  a  feeling  of  much  greater  freshness,  both  before  and 


THE  RITUAL  OF  A  SURGICAL  OPERATION         51 

after  an  operation,  when  garments  are  changed.  But  I  am, 
no  doubt,  hke  Jonah  preaching  to  a  converted  Nineveh. 
All  these  matters  are  now  a  part  of  our  daily  routine. 

The  method  of  the  preparation  of  our  hands  and  arms 
is  important.  It  is  still  a  common  thing  to  see  hands 
washed  in  a  basin  of  still  water.  The  moment  the  hands 
are  soaped  and  rinsed  the  water  is  polluted  by  the  dirt 
washed  off  the  skin.  If  the  washing  is  continued  it  is 
obvious  that  the  hands  are  being  constantly  re-infected 
from  the  contaminated  water.  If  the  water  is  emptied 
away,  and  fresh  poured  in,  the  basin,  being  polluted  by 
the  water  it  formerly  contained,  defiles  the  fresh  water. 
And  it  is  really  not  uncommon  to  see  a  piece  of  soap  used 
to  lather  the  hands,  laid  down,  and  picked  up  again, 
regardless  of  the  fact  that  each  contact  of  the  soap  with 
something  else  is  a  possible  method  of  soihng  it.  The 
best  of  all  plans  is  to  wash  under  running  sterile  water. 
Some  years  ago  I  had  water-tanks  made,  to  hold  five 
or  six  gallons,  fitted  with  a  dispensary  tap,  and  placed 
over  gas-coils,  so  that  the  water  contained  in  them  might 
be  boiled.  When  the  water  boils  the  tap  is  tm-ned,  and 
about  a  gallon  of  water  allowed  to  run  through  to  sterihze 
the  tap,  on  the  end  of  which  a  boiled  plug  is  fitted  until 
the  time  comes  for  use.  In  a  hospital  installation  it  is 
easy  to  arrange  for  the  tanks  to  be  sterihzed  by  steam  and 
to  be  cooled  by  water  running  through  a  coiled  pipe  in  the 
tank.  Water  can  be  boiled  for  a  quarter  of  an  hour, 
and  cooled  sufficiently  for  use  in  five  minutes.  Over  the 
tank  is  placed  a  tap  for  refilling. 

Almost  all  commercial  soaps  are  sterile.  The  outer 
surface,  of  course,  may  be  polluted,  but  when  this  is  washed 
or  scraped  away  the  exposed  fresh  surface  of  the  soap  is 
sterile.     Two  methods  of  using  soap  are  simple  and  satis- 


52  ESSAYS  ON  SURGICAL  SUBJECTS 

factory:  to  use  a  tablet  of  any  household  soap  which 
has  been  lying  in  a  solution  of  acrosyl  for  half  an  hour; 
or  to  steriUze  some  green  soft  soap  in  a  flat  dish  in  the 
autoclave,  and  to  rub  oflP,  time  after  time,  with  a  sterile 
gauze  swab,  enough  of  the  soap  to  form  a  good  lather. 
After  washing  for  not  less  than  fifteen  minutes  the  hands 
should  be  gently  rubbed  with  gauze  wet  in  spirit  and 
biniodide  solution,  or  in  a  solution  of  acrosyl,  which  is 
the  antiseptic  least  likely  to  damage  the  skin.  There  is  a 
great  difference  in  the  facility  with  which  a  hand  can  be 
cleaned;  some  rough,  chapped  hands,  coarsened  by  anti- 
septics, clean  with  great  difficulty;  smooth  hands,  well 
cared  for,  are  sterile  very  soon.  A  surgeon's  hand  should 
be  always  carefully  tended;  nails  should  be  kept  clean 
and  short  and  smooth,  and  the  skin  like  satin.  Once  a 
week  or  so  a  visit  to  a  manicurist  is  desirable. 

Gloves  are  almost  universally  worn  during  operations. 
I  know  only  three  surgeons  the  world  over  who  are  in  the 
first  rank  who  do  not  constantly  wear  gloves  during  opera- 
tions. The  arguments  in  favour  of  their  use  are  un- 
answerable. A  glove  properly  prepared  is  sterile,  and 
remains  so  if  put  on  the  hand  without  its  outer  side  being 
touched  by  any  except  the  glove  of  the  other  hand  or  a 
piece  of  sterile  gauze.  With  practice  it  is  rare  to  puncture 
a  glove  except  in  bone  operations,  and  for  these  it  is 
often  an  advantage  to  wear  thin  cotton  gloves  over  the 
rubber.  If  a  puncture  does  occur,  a  finger  stall  may  be 
put  on,  or  the  glove  changed  in  a  few  seconds.  The  bare 
hand  is  difficult  to  sterilize  in  some  cases;  it  is  almost  im- 
possible to  keep  it  sterile  throughout  an  operation,  as  the 
silk- thread  experiment  of  Kocher  shows;  if  it  is  infected 
during  an  operation  it  can  certainly  not  be  used  uncovered 
again  with  safety  during  that  operation. 


THE  RITUAL  OF  A  SURGICAL  OPERATION         53 

A  surgeon  may  say  that  he  uses  gloves  only  for  septic 
cases.  Does  he  always  know  when  an  operation,  or  any 
stage  in  it,  is  to  be  septic?  If  he  inadvertently  soils  his 
hand  when  a  septic  area  is  unexpectedly  discovered,  does 
he  then  put  on  gloves?  Has  he  them  always  ready  to 
wear?  Or  does  he  use  an  antiseptic  in  the  hope  of  com- 
bating the  infection  which  he  spreads  with  every  touch? 
Is  it  not  the  simpler,  safer,  more  certain  way  to  wear 
gloves  which  are  certainly  sterile,  and  to  change  them 
when  there  is  any  doubt  as  to  their  defilement? 

But  about  the  wearing  of  gloves  a  good  deal  may  be 
said.  Often  they  are  a  mere  fetish.  How  often  are 
gloves  put  on  without  their  outer  surfaces  being  touched 
or  stroked  by  a  bare  hand?  How  often  are  they  consid- 
ered rather  a  protection  for  the  surgeon  than  for  the 
patient?  I  have  seen  gloves  put  on  carefully,  and  the 
gloved  hand  then  used  to  palpate  an  abdomen  imperfectly 
smeared  with  iodine.  I  have  seen  a  blanket  which  covered 
a  patient's  legs  pulled  up  towards  his  body  by  a  gloved 
hand  which  a  few  minutes  later  was  inside  the  patient's 
abdominal  cavity;  and  I  have  seen  cleaned  hands  gloved 
and  unclean  forearms  left  bare  on  more  than  one  occasion. 
I  have  seen  gloves  used  in  the  earher  stages  of  operation, 
and  removed  when  a  difficulty  arose  in,  say,  an  operation 
upon  an  enlarged  thyroid  gland,  or  an  operation  for  hernia. 
This  is  a  technical  sin  of  the  gravest  kind.  Gloves  may  be 
sterilized  by  boihng,  or  be  placed  in  the  autoclave  with  the 
dressings  and  sVabs  and  used  dry.  The  advantage  of  the 
dry  glove  is  that  it  is  more  comfortable  to  wear  during  a 
long  fist  of  operations,  and  that  the  hand  being  covered 
by  a  dry  sterile  powder  is  kept  free  from  moisture.  A 
chance  puncture  of  the  glove  does  not  involve  the  escape 
of  a  possibly  contaminated  fluid  into  the  wound.     Gloves 


54  ESSAYS  ON  SURGICAL  SUBJECTS 

should  be  kept  on  the  hands  till  the  dressing  of  the  wound 
is  complete,  and  until  the  coat  and  sleeves  are  removed. 
If  gloves  are  properly  sterlized  and  properly  put  on,  the 
covered  finger  may  be  used  to  explore  a  knee-joint  or 
anywhere  else  with  impunity. 

The  "knife-and-fork"  method  of  operating,  in  which 
only  instruments  are  handled  for  every  purpose,  including 
the  tying  of  Hgatures,  is  a  confession  that  the  gloves  cannot 
be  trusted  by  the  operator.  If  the  bare  hand  is  used  during 
operations  there  is  a  risk  which  approaches  certainty  that 
the  wound  will  be  cont£iminated.  This  contamination 
may  be  lessened  in  its  meJignancy  by  the  immediate 
application  of  antiseptics,  or  by  the  free  and  frequent 
washing  of  the  hands  in  a  bactericidal  solution;  but  the 
results  either  of  mild  contamination  or  of  the  irritation 
of  antiseptics  in  the  wound  are  expressed  in  those  quadities 
of  its  healing  to  which  I  have  referred.  Many  years 
ago,  before  I  began  to  use  "tetra"  cloths  to  cover  the  skin 
around  the  wound  up  to  its  edges,  we  found  that  when 
cultures  were  taken  from  a  wound  they  became  progres- 
sively more  numerous  the  longer  the  incision  remained 
open;  but  many  an  infected  wound  healed  by  what  we 
were  then  content  to  call '  'first  intention. ' '  We  soon  learnt 
that  there  was  a  degree  of  "clinical  steriHty"  of  a  wound 
which  was  far  removed  from  the  "absolute  steriHty"  which 
it  should  be  our  endeavour  always  to  secure,  and  which 
alone  allows  of  "perfect"  flawless  heahng  and  a  convales- 
cence free  from  suffering.  Above  the  gloves  worn  by  all 
those  directly  engaged  in  the  operation  no  bare  arm 
should  be  seen.  Either  a  long-sleeved  gown  should  be 
worn,  or  sleeves  which  fit  firmly  round  the  wrist,  there  to 
be  covered  by  the  cuff  of  the  glove. 

Among  the  more  important  questions  involved  in  the 


THE  RITUAL  OF  A  SURGICAL  OPERATION         55 

ritual  of  a  surgical  operation  is  that  concerned  with  the 
preparation  of  the  skin.  The  skin  does  not  always,  indeed 
does  not  often,  harbour  organisms,  either  on  the  surface 
or  in  the  depths  of  sweat  or  sebaceous  glands,  of  any- 
special  septic  mahgnancy;  but  one  can  never  be  certain 
to  what  contact  the  skin  has  been  subject,  and  therefore 
it  is  always  uncertain  whether  septic  organisms  or  spore- 
bearing  bacilli  are  present  or  not.  It  is  always  necessary 
so  to  prepare  the  skin  for  a  w  ide  area  around  the  wound  to 
be  inflicted  that,  so  far  as  is  humanly  possible,  no  con- 
tamination of  the  wound  shall  be  caused  from  this  source. 
Infection  may  be  conveyed  to  the  skin  of  the  surgeon's 
hands  by  the  examination  of  discharging  wounds,  by 
rectal  or  vaginal  or  buccal  examinations,  or  during  an 
operation.  This  possibiUty  should  be  prevented  by  the 
avoidance  of  any  contact  with  patients,  in  these  circum- 
stances, unless  gloves  are  worn.  The  principle  of  "ab- 
stinence" is  the  safest:  the  surgeon  abstains  from  soiling 
his  hands  by  contact  with  any  potentially  infective  agent. 
^  It  is  exceedingly  difficult  so  to  sterilize  the  human  skin 
that  it  wiU  long  remain  sterile,  as  all  the  experiments 
conducted  in  recent  years  have  shown.  When  a  germi- 
cidal solution  is  applied  to  the  skin,  there  is  a  "clean  fight," 
so  to  speeds.,  between  the  solution  and  the  germs  lying  in 
or  on  the  skin.  The  value  of  the  solution  as  a  germicide 
is  therefore  easy  to  test,  and  results  obtained  by  these 
experiments  may  be  accepted  as  of  great  value.  It  is 
far  otherwise  when  a  germicidal  solution  is  apphed  to  a 
wound,  especially  to  an  open  wound  a  few  days  old, 
wherein  reparative  processes  have  begun.  In  such  a 
wound  an  innumerable  number  of  side  contests  are 
introduced;  it  is  no  longer  a  fight  between  a  germ  and  a 
germicide.    There  are  the  cellular  and  the  fluid  contents 


56  ESSAYS  ON  SURGICAL  SUBJECTS 

of  the  wound  discharge,  and  the  various  actions  and 
reactions  produced  among  them,  the  wound  surfaces,  the 
dressings,  and  the  germicide  all  to  be  taken  into  account. 
It  is  a  matter  of  interest  to  consider  whether  we  do  not 
go  far  astray  when  we  assess  the  value  of  a  germicide  in  an 
experiment  in  vitro,  and  then  expect  an  equivalent  germi- 
cidal action  to  be  produced  in  an  open  wound.  It  is,  I 
think,  very  doubtful  whether  the  "antiseptic"  action 
produced  by  the  addition  of  a  particular  chemical  sub- 
stance to  a  wound  is  due  to  those  properties  which  it 
possesses  as  a  bactericide.  It  probably  possesses  other 
properties  also  which  are  not  strictly  related  to  its  germi- 
cidal power.  But  in  the  case  of  the  skin  no  such  perplex- 
ing problems  arise.  The  efficacy  of  any  germicide  can  be 
tested  quite  easily ;  and  the  results  of  experiments  should 
here  guide  our  practice.  A  surgeon  may  say  that  he  is 
satisfied  with  the  healing  of  his  wounds  when  he  might 
quite  easily  have  better  results  by  using  better  methods 
of  skin  sterihzation.  By  cUnical  experience,  which  is 
tedious  and  lengthy,  we  may  at  last  realize  the  value  of 
skin  disinfection,  which  we  might  have  determined  at 
once  by  experiment.  By  experience  we  find  a  short  way 
by  a  long  wandering. 

What  are  the  requirements  for  an  ideal  skin  disin- 
fectant? It  should  be  cheap  and  easily  accessible,  simple 
in  its  appHcation,  non-irritant,  capable  of  penetrating  the 
skin  to  some  depth;  it  should  be  effective  in  destroying  in 
a  short  time  all  of  the  organisms  which  are  found  on  or  in 
the  skin,  and  it  should  do  nothing  to  prevent  or  delay  the 
clean  and  speedy  healing  of  the  wound. 

The  skin  disinfectant  most  commonly  employed  is 
iodine.  It  is  applied  in  varying  strengths,  and  in  different 
vehicles — spirit,  chloroform,  acetone,  benzine,  etc.    The 


THE  RITUAL  OF  A  SURGICAL  OPERATION         57 

tincture  of  iodine  is  the  form  which  is  most  often  used. 
Both  experimentally  and  clinically  the  method  is  clearly  of 
the  second  rate.  The  work  of  Tinker  and  Prince,  Hunter 
Robb,  Stanton,  and  others,  shows  that  even  when  the  iodine 
is  allowed  to  remain  on  the  skin  which  is  tested,  sterilization 
is  not  always  indicated  by  the  culture  tube;  if  the  iodine  is 
removed  by  a  solution  of  potassium  iodide,  and  the  skin 
washed  with  sterile  water  and  examined,  infection  is 
demonstrable  in  over  50  per  cent,  of  cases.  A  very  large 
proportion  of  the  iodine  used  often  disappears  from  the 
skin  before  the  operation  is  completed.  There  is  notliing 
then  to  reconomend  iodine  but  the  ease  and  rapidity  with 
which  it  can  be  appUed  and  its  colouring  of  the  skin ;  its 
efficacy  is  far  less  than  is  required,  and  it  is  a  powerful 
irritant.  Iodine,  to  be  effective,  must  be  apphed  on  a  dry 
skin,  which  often  means  a  dirty  skin.  I  have  more  than 
once  seen  a  smear  of  iodine  apphed  over  grime  and  filth 
that  could  not  be  sterihzed  by  a  dozen  similar  appHcations. 
I  have  used  iodine  myself  on  a  great  many  occasions,  and 
have  given  it  a  fair  trial;  I  have  seen  it  in  a  very  large 
number  of  clinics;  yet  I  have  very  rarely  seen  a  wound 
heal  with  all  those  attributes  which  are  necessary  before 
one  is  entitled  to  say  that  it  is  "perfect"  when  iodine  alone 
has  been  apphed.  Picric  acid  in  alcohohc  solution  of  a 
3  per  cent,  or  5  per  cent,  strength  gives  better  results  than 
iodine;  but  it  does  not  penetrate  deeply,  and  it  is  not  of 
sufficient  bactericidal  value.  The  wounds  are,  again,  not 
up  to  the  highest  standard  in  a  large  number  of  cases. 

Brilhant  green  is  perhaps  the  most  effective  of  all  the 
aniline  group  of  antiseptics  when  applied  to  the  skin. 

By  far  the  best  method  of  preparing  the  skin  that  I 
have  ever  used — and  I  have  tried  and  tested  many — 
is  carried  out  in  three  stages:  (1)  Abundant  washing  with 


58  ESSAYS  ON  SURGICAL  SUBJECTS 

soap  and  water,  preferably  ether  soap;  (2)  gentle  friction 
with  biniodide  of  mercury  and  spirit  solution  1 :  500 ;  (3) 
drying;  followed  by  the  appUcation  for  two  to  three 
minutes  of  Harrington's  solution.  When  the  towels  are 
fixed  round  the  operation  area  a  further  apphcation  of 
Harrington's  solution  is  made;  and  throughout  all  opera- 
tions the  skin  is  covered  with  towels  so  that  no  friction  of 
the  hands  against  it  is  possible.  It  would  be  well  if 
surgeons  the  world  over  took  a  Httle  more  pride  in  the 
wounds  they  inflict.  The  appearance  of  a  wound  is  often 
the  best  index  to  the  quahty  of  the  work  that  has  been 
done  throughout  the  operation. 

The  towels,  which  should  surround  the  operation  area 
as  closely  as  possible,  are  fixed  to  the  skin  by  cHps.  On 
the  surface  of  the  skin  left  exposed  a  series  of  tiny 
scratches  are  made  by  a  very  thin  needle,  at  right  angles 
to  the  proposed  Kne  of  incision.  These  are  for  the  purpose 
of  indicating  where  the  stitches  are  to  be  introduced  when 
the  wound  is  sutured.  Unless  there  is  a  mathematical 
accuracy  of  apposition  there  is  never  perfect  beauty  in  a 
wound  or  scar,  and  accuracy  of  apposition  is  difficult  or 
impossible  unless  some  method  of  this  kind  is  adopted 
to  seciu-e  it. 

In  so  far  as  the  actual  operation  is  concerned,  it  is,  for 
the  reasons  I  have  given,  essential  to  avoid  contact  with 
the  skin  of  a  patient  as  much  as  possible.  The  hands 
should  not  touch  the  skin  at  all,  viscera  should  not  be 
allowed  to  He  upon  it,  and  the  rubbing  of  instruments 
against  it  must  be  avoided.  As  soon  as  the  incision  is 
made,  cloths  of  several  thicknesses  of  gauze  or  towelHng 
are  fixed  to  the  skin  edges  and  dip  well  into  the  wound. 
If  these  "tetra"  cloths  he  loosely  on  the  parts  around  the 
wound,  they  ruffle  up  during  the  movements  of  the  sur- 


THE  RITUAL  OF  A  SURGICAL  OPERATION         59 

geon's  hands.  If  powder  is  dusted  on  the  under  surface 
of  them  it  is  soon  found  to  lie  in  the  wound.  The  towels 
must,  therefore,  be  held  at  points  distant  from  the  wound, 
so  that  they  are  kept  stretched  and  fixed  throughout  the 
operation.  When  they  are  removed  at  the  conclusion  of 
the  operation,  the  skin  covered  by  them  is  washed  over 
with  spirit  and  with  Harrington's  solution  before  any 
stitches  are  inserted. 

The  wound  is  made  by  a  firm,  clean  sweep  of  the  knife. 
Any  bunghng  here  makes  an  irregular,  ugly  wound.  A 
good  many  of  the  scalpels  made  nowadays  are  peculiarly 
unfitted  for  their  work.  I  use  only  two  patterns:  one 
with  a  deep  belly,  made  for  me  by  Stille  of  Stockholm 
originally,  and  the  other  Stiles'  pattern,  which  is  used  for 
all  dissections.  All  vessels  are  cHpped  if  possible,  as  in 
a  hernia  operation,  before  being  cut,  but  certainly  the 
moment  they  are  cut.  If  blood  leaks  into  a  wound  it 
stains  the  tissues,  and  makes  subsequent  dissection  along 
the  "white  fine"  very  difficult. 

I  say  that  "vessels"  are  chpped.  Most  of  the  clips 
made  seize  not  only  the  vessels  but  a  mass  of  tissue 
surrounding  them.  When  ligatures  are  applied,  all  this 
tissue  is  strangled  in  the  Hgature,  and  has  to  be  digested  by 
leucocytes  in  the  wound.  The  tips  of  artery  clips  should 
be  narrow — almost  pointed — and  should  seize  the  very 
smallest  possible  portion  of  tissue  with  the  vessel.  If 
dissection  is  carried  on  in  a  wound,  as  when  glands  of  the 
neck,  or  of  the  breast  in  a  case  of  carcinoma,  are  removed, 
gentle  traction  in  one  direction  by  the  surgeon,  and  in  the 
opposite  by  his  assistant,  will  reveal  a  fluffy  layer  of  thin 
areolar  tissue,  the  "white  fine"  as  I  always  call  it,  along 
which  dissection  can  proceed  very  easily  and  quickly,  and 
with  the  immediate  disclosure  of  all  the  vessels  which  must 


60  ESSAYS  ON  SURGICAL  SUBJECTS 

be  seized.  This  involves  the  application  of  many  clips, 
but  the  wound  should  always  be  kept  dry  and  unstained 
by  blood.  Kocher  was  accustomed  to  put  out  twenty 
dozen  chps  for  a  goitre  operation,  and  on  many  occasions 
he  seemed  to  use  most  of  them.  It  should  be  our  ideal 
to  complete  such  an  operation,  which  in  my  student  days 
was  often  one  involving  much  loss  of  blood,  without 
staining  the  towels  round  the  wound. 

Though  traction  is  necessary  in  gland  and  goitre  op- 
erations, it  must  be  avoided  in  abdominal  work.  There 
every  pull  means  a  pain.  I  dislike  abdominal  retractors 
intensely.  The  forcible  and  merciless  retraction  of  the 
abdominal  wall  throughout  a  long  operation  cannot  fail 
to  cause  shock  and  suffering  afterwards.  The  best 
retractor  is  the  gentle  light  hand  of  a  well-trained  as- 
sistant, used  mercifully  when  it  must  be  used  at  all.  But 
with  adequate  incisions,  retraction  is  very  Httle  needed 
during  the  greater  part  of  most  operations. 

Dissection  may  be  carried  out  in  two  manners:  by 
the  knife  or  by  "gauze  stripping."  If  by  the  knife,  the 
movements  should  be  short,  sharp,  close  together,  so  that 
if  recorded  on  a  moving  drum  the  picture  would  resemble 
a  "feather  edge."  And  the  knife  must  be  sharp.  Big, 
heavy,  clumsy  movements  with  a  dull  km'fe  hurt  the 
patient,  and  leave  the  parts  less  fitted  to  heal.  Through- 
out the  operation  there  must  be  no  undue  exposure  of 
parts.  In  a  large  dissection,  such  as  that  required  in  re- 
moval of  a  cancer  of  the  breast,  the  dissection  extends  from 
the  axilla  to  the  umbilicus,  and  from  the  opposite  pectoral 
muscle  over  the  latissimus  dorsi.  With  skin  flaps  turned 
back,  the  bared  area  is  very  extensive.  It  should  never 
be  seen  as  a  whole.  As  one  part  of  the  dissection  is  com- 
pleted, hot  moist  mackintosh  cloths  are  placed  over  the 


THE  RITUAL  OF  A  SURGICAL  OPERATION         61 

raw  surface  to  prevent  drying  and  chilling,  and  the  chance 
of  contamination.  Similarly,  in  abdominal  work,  only  that 
part  of  the  operation  field  should  be  seen  with  which  the 
operator  is  at  the  moment  engaged.  There  is  no  need  in 
the  operation  of  gastro-enterostomy,  for  example,  for  any- 
thing to  be  outside  the  abdomen  during  the  suturing  of 
the  viscera  except  that  small  part  of  each  which  is  em- 
braced by  the  clamps.  The  patient  is  accustomed  to  keep 
his  own  viscera  warm,  and  he  should  still  be  allowed  to  do 
so.  Crile's  work  has  shown,  to  my  mind  conclusively, 
the  need  for  avoiding  cooHng  or  drying  of  wound  surfaces. 

All  the  instruments  used  during  the  operation  are,  of 
course,  sterilized  by  heat;  but  it  is  important  to  remember 
that  contamination  may  occur  during  an  operation,  and 
therefore  the  various  chps,  scissors,  retractors,  or  other 
instruments  should  be  resterihzed  as  often  as  is  necessary. 
If,  for  example,  a  pair  of  scissors  are  used  to  open  the 
intestine  in  a  case  of  gastro-enterostomy  or  colectomy,  or 
needles  to  suture  viscera  together,  they  are  at  once  dis- 
carded, and  never  used  again  till  they  have  been  boiled. 
The  mucosa  may  be  sterile  in  a  case  of  gastro-enterostomy, 
but  one  can  never  be  certain,  and  it  is  safer  always  to 
assume  that  any  possibly  infected  tissue  is  infected. 

In  operations  for  mahgnant  disease,  frequent  steriliza- 
tion of  instruments  is  most  necessary.  For  example,  in 
removing  a  breast  for  carcinoma,  many  surgeons,  of  whom 
I  am  one,  adopt  the  method  suggested  by  Rodman  and 
Willy  Meyer,  and  complete  the  axillary  dissections  first. 
There  are  many  advantages  in  so  doing  which  need  no 
mention  now.  Every  instrument  used  in  this  dissection — 
knife,  clips,  scissors — may  possibly  be  brought  into  contact 
with  a  cancer  cell.  When  once  used  it  is  therefore  laid 
aside,  and  not  taken  up  again  till  it  has  been  reboiled. 


62  ESSAYS  ON  SURGICAL  SUBJECTS 

Cancer  cells,  as  Ryall  and  others  have  shown,  can  be 
grafted  on  to  the  patient's  own  tissues  and  develop  a  new 
deposit  of  cancer.  It  is  obvious  that  the  graft  may  be 
conveyed  to  any  instrument,  or  on  the  gloved  hand  if  it 
is  at  work  in  the  wound.  In  all  operations  I  have  a  red 
handkerchief  placed  on  the  table  which  hes  over  the  legs 
of  the  patient.  As  soon  as  any  instrument  is  soiled  I 
place  it  on  this  danger  spot,  and  it  is  at  once  removed  by 
the  nurse  to  the  steriHzer. 

As  regards  the  material  used  for  ligatures  and  sutures 
which  must  remain  within  the  wound,  certain  conditions 
are  essential.  Such  material  should,  ideally :  (1)  Achieve 
its  purpose — be  sufficient  to  hold  parts  together,  close  a 
vessel,  etc.;  (2)  disappear  as  soon  as  its  work  is  ac- 
complished; (3)  be  free  from  infection;  and  (4)  be  non- 
irritant. 

The  only  material  which  can  be  made  to  fulfil  these 
conditions  is  catgut.  Catgut  can  be  steriUzed  perfectly. 
The  method  of  Claudius,  which  directs  that  the  catgut 
should  be  soaked  in  a  solution  consisting  of  iodine  1  per 
cent,  and  potassium  iodide  1  per  cent,  in  water,  ignores 
the  fact  that  with  such  a  proportion  of  iodide  of  potassium 
all  the  iodine  is  not  dissolved ;  much  of  it  lies  inert  at  the 
bottom  of  the  vessel.  I  use  a  solution  made  in  accordance 
with  their  atomic  weights,  iodine  in  a  strength  of  1  per 
cent,  and  iodide  of  potassium  in  a  strength  of  1.75  per 
cent. ;  the  whole  of  the  iodine  is  then  taken  up,  a  darker 
and  stronger  solution  results,  and  catgut  soaked  in  this 
for  ten  days  or  more  is  almost  black  in  colour,  and  so 
strongly  permeated  by  iodine  that  it  is  exceedingly  difficult 
to  infect  it.  I  have  never  known  any  surgeon  use  silk 
and  not  have  trouble  from  it.  Silk  for  Ugatures  is  not 
necessary,  for  catgut  will  securely  tie  any  vessel.     Silk  for 


THE  RITUAL  OF  A  SURGICAL  OPERATION         63 

intestinal  sutures  is  not  necessary.  Certainly  I  have  not 
used  any  for  fifteen  years,  and  I  have  now  discarded  hnen 
thread  for  all  but  the  anastomoses  after  colectomy.  An 
unabsorbable  suture  used  to  effect  the  junction  in  gastro- 
enterostomy is  possibly  a  factor  causing  the  development 
of  a  jejunal  ulcer.  But  thick  chromic  catgut  also  will 
remain  for  years  at  a  suture  Hue  in  such  a  case.  In  one 
patient  I  have  found  a  piece  of  chromic  catgut  over 
two  inches  long  dangUng  at  the  gastrojejunal  opening 
three  years  and  nine  months  after  the  anastomosis  had 
been  made.  It  is,  of  course,  as  I  have  before  pointed  out, 
the  sero-serous  suture  which  is  the  offender  in  such  in- 
stances. The  inner  mucous  suture,  no  matter  of  what 
material,  is  soon  loosened  and  escapes. 

Probably  we  all  use  more  sutures  than  are  necessary  in 
intestinal  anastomoses.  In  urgent  cases  I  have  more  than 
once  used  a  single  Connell  suture  with  perfect  success. 
But  in  surgery,  in  order  to  be  certain  that  you  have  done 
enough,  it  is  generally  prudent  to  do  more  than  is  neces- 
sary. Over  and  over  again  I  put  in  an  additional  stitch 
here  and  there.  I  know  it  is  not  really  needed,  but  I  call 
it  my  "hypnotic"  stitch;  for  I  sleep  better  at  night  when 
I  know  it  is  there. 

The  most  important  person  present  at  an  operation  is 
the  patient.  This  is  a  truth  not  everywhere  and  always 
remembered.  It  is  our  duty  to  make  the  operation 
as  Httle  disagreeable  as  possible  for  him.  To  many 
patients  it  is  a  dreaded  ordeal.  Our  patients  today  are 
terrified  by  the  tradition  that  cUngs  to  the  word  "opera- 
tion," a  tradition  started  in  the  days  when  it  must  indeed 
have  been  a  terrible  procedure,  without  anaesthetics  other 
than  those  stupefying  drugs,  alcohol  and  tobacco,  with 
patients  strapped  down  or  held  by  assistants,  and  all  the 


6U  ESSAYS  ON  SURGICAL  SUBJECTS 

other  horrible  accessories.  Today  an  operation  can,  and 
should,  be  made  a  very  simple  matter,  devoid  entirely  of 
anything  repellent  or  disheartening. 

The  preliminary  use  of  scopolamine,  atropine  and 
morphine,  or  of  omnopon  is  a  very  valuable  help.  One 
dose  of  T^  gr.  atropine  and  about  ^h  or  -^  gr.  scopol- 
amine and  i  or  T  gr.  morphine  is  needed,  according  to  the 
patient's  age,  size,  etc.  This  is  given  about  three- 
quarters  of  an  hour  before  operation.  In  a  private 
hospital  the  blinds  should  then  be  drawn  down,  the  room 
darkened,  and  the  patient  encouraged  to  sleep.  No  talk- 
ing is  allowed.  The  nurse  remains  in  the  room,  but  is 
warned  not  to  speak,  and,  of  course,  no  friends  are  then 
permitted  to  see  the  patient.  When  the  patient  is  taken 
to  the  operation  theatre  as  quietly  as  possible,  a  towel 
covers  the  eyes  and  the  operation  room  itself  is  dark. 
No  conversation  is  allowed  in  the  theatre,  and  only  the 
anaesthetist  and  one  nurse,  or  possibly  two  nurses,  remain. 
Everything  is  kept  as  quiet  and  orderly  as  possible. 
About  one-third  of  the  patients  subsequently  say  they 
have  little  or  no  recollection  of  going  to  the  theatre  or  of 
taking  the  anaesthetic.  All  abdominal  cases  are  treated 
by  Crile's  method  of  quinine  and  urea  injections  into  the 
parietal  peritoneum,  and  into  the  nerve-trunks  running 
to  the  area  in  which  the  operation  takes  place.  There  is 
no  doubt  as  to  the  diminution  of  pain  thereby  resulting. 
With  shock  we  are  not  much  concerned.  There  are  very 
few  occasions  indeed  when  shock  results  from  an  ab- 
dominal operation  properly  conducted,  when  the  patient 
is  kept  warm  on  the  table  by  one  device  or  another,  and 
when  the  gentlest  handhng,  the  most  careful  haemostasis, 
and  adequate  protection  of  parts  have  been  exercised. 

Every  detail  in  every  operation  is  of  importance,  and 


THE  RITUAL  OF  A  SURGICAL  OPERATION         65 

should  be  conceived,  practised,  and  tested  with  unweary- 
ing patience  by  the  operator  himself,  and  by  him  in 
conjunction  with  all  his  assistants.  Was  it  riot  Michael 
Angelo  who  first  said  that  success  depends  upon  details, 
but  success  is  no  detail?  In  surgery,  at  least,  success  may 
well  depend  upon  the  scrupulous,  exacting,  and  unceasing 
supervision  and  close  scrutiny  of  every  smallest  incident 
of  procedure.  In  respect  of  surgical  work  there  may  be 
some  truth  in  Blake's  assertion  that  all  excellence  is  in 
minute  particulars.  Surgery  is  nowadays  no  longer  the 
work  of  an  individual,  but  of  a  "team"  in  which  every 
member  plays  his  exact  part,  in  which  all  contribute  to 
success,  and  in  which  each  may  bring  about  disaster.  The 
well-trained  team  should  display  that  mastery  which  is 
impKed  by  ease  in  smooth  and  efficient  action.  In  every 
phase  of  its  work  there  should  be  not  merely  the  casual 
observance  of  a  ritual  the  meaning  of  which  is  lost  and  the 
deeds  of  which  are  only  a  faded  counterfeit,  but  acts  of  full 
devotion  to  principles  which  have  been  tried  and  proved, 
acts  which  are  the  witnesses  to  a  hving  and  perfect  faith. 

It  is,  of  course,  a  platitude  to  say  that  a  good  surgeon 
is  not  merely  one  who  operates  well.  The  quahties  re- 
quired to  make  our  ideal  surgeon  are  many:  gifts  of 
character,  leadership,  wisdom — even  worldly  wisdom — 
compassion,  and  the  finest  technical  skill.  In  respect  of 
the  latter  we  remember  that  surgery  is  not  only  a  science 
but  an  art,  work  demanding  the  highest  craftsmanship, 
and  a  knowledge  of  all  the  "tricks  of  the  tools'  true  play." 

In  all  the  movements  of  the  surgeon  there  should  be 

neither  haste  nor  waste.     It  matters  less  how  quickly  an 

operation  is  done  than  how  accurately  it  is  done.     Speed 

should  result  from  the  method  and  the  practised  faciHty 

of  the  operator,  and  should  not  be  his  first  and  formal 
5 


66  ESSAYS  ON  SURGICAL  SUBJECTS 

intention.  It  should  be  an  accomplishment,  not  an  aim. 
And  every  movement  should  tell,  every  action  should 
achieve  something.  A  manipulation,  if  it  requires  to  be 
carried  out,  should  not  be  half  done  and  hesitatingly  done. 
It  should  be  deliberate,  firm,  intentional,  and  final. 
Infinite  gentleness,  scrupulous  care,  fight  handfing,  and 
purposeful,  effective,  quiet  movements  which  are  no 
more  than  a  caress,  are  all  necessary  if  an  operation  is  to 
be  the  work  of  an  artist,  and  not  merely  of  a  hewer  of 
flesh.  For  every  operation,  even  those  procedures  which 
are  now  quite  conomonplace  should  be  executed  not  in  the 
spirit  of  an  artisan  who  has  a  job  to  get  through,  but  in  the 
spirit  of  an  artist  who  has  something  to  interpret  or  create. 
An  operation  should  not  only  bring  refief  or  health  to  the 
patient,  but  should  give  a  glow  of  keen  defight  to  the 
artist  himself,  a  thrill  of  joy  and  a  sense  of  complete 
satisfaction  to  a  critical  spectator. 

Ours  has  been  a  necessary  profession  ever  since  man's 
body  was  subject  to  enmity  and  casualty.  AU  who  prac- 
tise it  wiU  need  the  gifts  of  which  Thomas  FuUer  spoke — 
"an  Eagle's  eye,  a  Lady's  hand,  and  a  Lion's  heart."  Of 
all  of  us  who  labour  honestly  may  it  at  last  truthfully  be 
said,  as  it  was  said  of  James  IV  of  Scotland,  "Quod  vulnera 
scientissime  tractaret" — "He  was  most  skilful  at  the 
handfing  of  wounds." 


THE   DIAGNOSIS  AND   TREATMENT   OF 
CHRONIC  GASTRIC  ULCER* 

Around  the  subject  of  gastric  ulcer  a  very  extensive 
literature  has  accumulated.  Every  country,  and  a  host  of 
authors,  have  contributed  to  it,  imtil  there  must  be  many 
who  doubt  whether  anything  really  fresh  or  important 
remains  to  be  said.  Yet  I  hold  a  firm  behef,  based  upon 
an  experience  the  length  of  which  I  dread  to  contemplate, 
that  no  small  part  of  what  is  written  requires  ruthless 
revision  in  the  hght  of  the  modern  methods  of  inquiry 
conducted  by  the  radiographer  and  the  surgeon.  The 
wealth  of  teaching  in  the  text-books  is  too  often  imper- 
sonal, and  represents  rather  a  legacy  flowing  from  one's 
ancestors  than  a  fortune  newly  won  by  hard  endeavour. 
The  heritage  in  respect  of  gastric  ulcer  is  heavy  enough, 
but  not  all  of  the  securities  are  worth  their  face  value. 

A  gastric  ulcer  is,  of  course,  an  ulcer  occurring  in  the 
stomach.  During  development  the  stomach  is  dijfferen- 
tained  as  one  part  of  the  foregut  from  that  other  part 
which  forms  the  duodenum  as  far  down  as  the  ampulla  of 
Vater.  The  foregut  terminates  at  the  point  of  entrance  of 
the  ducts  of  the  Kver  and  pancreas ;  at  the  end  of  the  second 
month  of  fetal  fife  the  pylorus  marks  oflP  the  stomach  from 
the  duodenum.  When  development  is  complete  it  is,  as  a 
rule,  easily  possible  in  all  periods  of  life  to  distinguish  the 
stomach  from  the  duodenum.  On  palpation  the  pyloric 
muscle  and  valve  are  felt  at  once.    Exactly  in  the  line 

*  A  paper  read  at  the  opening  of  the  Session  of  the  Harveian  Society,  October 
23,  1919.    Reprinted  from  the  British  Medical  Journal,  December  13,  1919. 

€7 


68  ESSAYS  ON  SURGICAL  SUBJECTS 

of  the  pylorus  a  thin  white  line  is  to  be  seen  on  careful 
examination;  the  line  becomes  clearer  if  in  the  living 
subject  the  pylorus  is  held  forward  by  a  finger  and 
thumb  placed  one  on  the  stomach,  the  other  on  the 
duodenum,  and  closed  to  meet  in  the  pylorus.  In  close 
proximity  to  the  "pyloric  white  Une"  is  a  vein,  the 
"pyloric  vein,"  which  begins  at  or  near  the  middle  of  the 
anterior  surface  of  the  pylorus  and  runs  downwards  to 
the  greater  curvature.  The  "pyloric  vein"  is  constant, 
its  arrangement  variable.  It  may  be  single  and  large, 
short  and  branched,  or  long  with  only  very  slender 
branches;  it  may  be  double;  it  may  or  may  not  be  met 
by  a  smaller  vein  running  up  towards  the  lesser  curvature; 
it  may  Ue  on  either  side  of  the  pyloric  white  line.  The 
perfectly  fair  criticism  has  been  made  against  the  accept- 
ance of  this  vein  as  a  landmark,  that  veins  are  very 
irregular  in  their  arrangement,  position,  and  distribution, 
and  that  nowhere  else  in  the  body  is  the  position  of  a 
vein  so  constant  as  this  is  asserted  to  be.  And  it  must 
be  frankly  admitted  that  there  is  a  very  small  number  of 
cases  in  which  the  venous  arrangment  is  such  that  no 
accurate  localization  of  the  pylorus  is  possible  from  a 
surface  inspection.  But  there  is  no  landmark  in  the 
body  that  is  invariable.  For  many  years  past  I  have 
drawn  the  position  of  this  vein  as  seen  during  an  operation 
while  the  parts  were  under  inspection,  and  it  is  quite  safe 
to  say  that  in  at  least  90  per  cent,  of  the  cases  the  markings 
I  have  mentioned  may  be  accepted  as  accurate.  Latarjet 
{Lyon  Chirurgicaly  1911,  vi,  337),  after  a  research  con- 
ducted for  the  purpose  of  deciding  the  value  of  the  vein 
as  an  accurate  landmark,  concludes  in  favour  of  its 
acceptance. 

An  ulcer  occurring  on  the  proximal  side  of  this  vein  is  a 


CHRONIC  GASTRIC  ULCER  69 

"gastric  ulcer";  an  ulcer  occurring  i  or  |  inch  or  more 
beyond  it  is  a  '  'duodenal  ulcer. "  It  is  not  merely  a  matter 
of  academic  interest  to  distinguish  them;  their  symptoms 
are  sufficiently  distinct  to  allow  an  accurate  diagnosis  of 
duodenal  ulcer  to  be  made  with  remarkable  constancy; 
their  comphcations  and  sec[uels  in  respect  of  perforation 
and  haemorrhage  are  very  different;  cancer  develops 
often  upon  the  base  of  a  gastric  ulcer,  and  almost  never 
upon  the  base  of  an  ulcer  in  the  duodenum.  Gastric  ulcer 
is  a  disease  of  comparative  rarity;  its  diagnosis  from  the 
clinical  evidence  alone  is  difficult;  its  mimicry  by  other 
conditions  extremely  frequent.  These  statements  may 
not  ffiid  a  ready  acceptance  everywhere.  For  if  the  text- 
books of  medicine,  or  the  special  works  of  distinguished 
authors  are  read,  or  if  the  diagnosis  made  in  the  out- 
patient medical  clinics  are  reviewed,  it  will  be  found  that 
there  is  a  general  agreement  that  gastric  ulceration  occurs 
frequently,  and  that  its  symptoms  are  of  a  kind  hardly 
admitting  of  doubt  or  difficulty  in  diagnosis.  I  have 
spent  a  great  deal  of  time  in  reading  almost  everything 
to  which  I  could  obtain  access  that  has  been  written 
about  gastric  ulcer,  and  I  am  compelled  to  say  that  when 
the  statements  univeraslly  made  are  tested  by  the  ex- 
perience gained  in  the  operation  theatre  they  are  found  to 
be  inaccurate.  My  contention  is  that  a  full,  clear,  and 
truthful  description  of  the  symptoms  of  gastric  ulcer  is 
rarely  given,  and  that  the  conditions  described  as  "gastric 
ulcer"  are  in  the  majority  of  cases  indicative  of  other 
diseases. 

What  are  the  symptoms  of  gastric  ulcer,  and  how  may 
the  diagnosis  be  made? 

Ulcer  of  the  stomach  occurs  twice  as  often  in  men  as  in 
women;  its  chief  symptom  is  pain.    All  the  attributes  of 


70  ESSAYS  ON  SURGICAL  SUBJECTS 

this  symptom  merit  and  must  receive  the  closest  scrutiny. 
The  chief  attribute  is,  I  think,  regularity.  In  all  cases  of 
gastric  ulcer  there  are  periods  of  intermission,  longer  or 
shorter,  at  one  period  of  the  year  or  another;  but  when 
the  attacks  are  present  the  pain  which  is  then  the  chief 
feature  always  displays  regularity.  It  comes  after  all 
meals,  even  hght  meals;  it  is  not  present  after  breakfast  on 
one  day,  after  dinner  on  another,  and  absent  entirely  on 
another  day.  If  a  meal  is  eaten,  pain  during  the  attack 
follows  invariably.  The  interval  between  the  taking  of 
the  meal  and  the  onset  of  pain  is  fairly  constant.  As  a 
rule  the  earher  the  pain  is  felt  after  a  meal,  the  nearer  is 
the  ulcer  to  the  oesophagus.  That  is  to  say,  if  pain 
comes,  regularly,  one  or  one  hour  and  a  half  after  a  meal, 
the  ulcer  that  causes  it  is  in  the  stomach,  it  is  a  "pre- 
pyloric" ulcer.  If  pain  comes  two,  three,  or  four  hours 
after  a  meal  the  ulcer  hes  generally  beyond  the  pylorus. 
This  period  of  rehef  from  pain  after  a  meal  is  constant 
and  invariable,  both  in  gastric  and  duodenal  ulcers,  until 
stenosis,  subacute  perforation,  or  the  formation  of  crip- 
pling and  embarassing  adhesions  takes  place.  These  con- 
ditions may  lead  to  a  delay  in  the  time  of  the  appearance 
of  the  pain  in  cases  of  gastric  ulcer,  or  to  the  hurried 
appearance  of  the  pain  in  cases  of  duodenal  ulcer. 

In  over  three  cases  in  five  of  gastric  ulcer,  seen  during 
operation,  the  pain  came  within  one  and  a  half  hours  of 
the  taking  of  food;  in  rather  more  than  four  cases  in  five 
of  duodenal  ulcer  the  pain  appeared  two  hours  or  more 
after  food.  The  pain  in  cases  of  gastric  ulcer  very  often 
disappears  after  an  hour,  or  even  less,  and  may  be  com- 
pletely reheved,  indeed,  it  generally  is,  before  the  next 
meal  is  due.  The  pain  of  duodenal  ulcer,  on  the  other 
hand,  appearing  later,  generally  persists,  often  with  a 


CHRONIC  GASTRIC  ULCER  7i 

slowly  increasing  severity,  until  the  meal  is  taken.  The 
character  of  the  meal  influences  the  pain.  A  generous 
meal  of  heavy  foods  causes  severe  pain  to  appear  at  an 
earher  time  in  gastric  ulcer;  it  delays  the  appearance  of 
the  pain  in  cases  of  duodenal  ulcer.  Smaller  meals  of 
soft,  pultaceous  food,  easy  of  digestion  and  easily  pro- 
pelled, produce  less  pain,  and  the  interval  of  relief  brought 
by  the  food  is  longer.  An  indiscreet  and  hasty  meal,  espe- 
cially of  fruits,  or  salads,  or  pastry,  may  give  instant  and 
grievous  pain.  A  bland  and  blameless  diet  taken  in  small 
quantities  at  brief  intervals  may  reduce  the  chances  of 
pain  appearing,  or  even  afford  complete  relief.  In  a  small 
proportion  of  cases  pain  may  not  be  influenced  by  food  in 
the  manner  and  to  the  extent  now  described.  When  the 
ulcer  is  near  the  cardia  there  may  be  no  rehef  from  taking 
food,  or  pain  may  inamediately  be  made  worse;  each  of 
these  features  is  present  in  approximately  4  per  cent, 
of  the  cases. 

The  pain  is  variously  described:  it  is  a  deep,  * 'boring,'* 
"burning,"  or  "aching"  pain;  there  may  be  "gnawing" 
or  a  sense  of  acidity  and  a  desire  for  food  or  warmth.  The 
pain  in  a  majority  of  cases  is  said  to  be  on  the  left  side  or 
high  in  the  epigastrium;  in  some  severe  types  there  may 
be  great  complaint  of  pain  in  the  back.  In  twenty-three 
cases  in  which  there  was  a  deep  excavation  in  the  pan- 
creas consecutive  to  a  subacute  perforation  of  the  ulcer  on 
the  lesser  curvature  or  posterior  wall  of  the  stomach, 
seventeen  patients  complained  bitterly  of  the  intolerable 
aching  in  the  back.  As  we  know,  many  patients  attacked 
with  acute  pancreatitis  suffer  most  from  pain  in  the  back, 
and  it  is  an  old  observation  and  an  accurate  one  that  a 
deep  eroding  ulcer  of  the  pancreas  may  also  produce  this 
most  distressing  symptom. 


n  ESSAYS  ON  SURGICAL  SUBJECTS 

The  position  of  the  ulcer,  its  freedom  from  adhesion  to 
neighbom'ing  parts,  and  its  size,  all  seem  to  affect  the 
type  of  pain,  its  periods  of  latency,  and  its  time  of  onset 
after  meals.  When  ulcers  are  small  and  seated  high  up  on 
the  lesser  curvature,  or  just  on  the  posterior  surface,  the 
symptoms  are  shorter  in  duration,  but  more  prone  to 
recurrence.  They  are  often,  as  we  learn  from  the  radio- 
graphic examination,  attended  by  severe  forms  of  local 
spasm,  which  are  responsible  for  the  sensations  of  dis- 
tension, weight,  and  pressure,  which  appear  to  accompany 
these  ulcers  more  often  than  those  of  other  types.  If  the 
ulcer  is  large,  excavating  the  hver,  or  burrowing  deeply 
into  the  pancreas,  or  if  it  is  fixed  by  firm  broad  adhesions 
to  the  abdominal  wall  or  the  Hver,  the  symptoms  are  less 
likely  to  show  those  intermissions  which  are  so  charac- 
teristic of  the  earlier  stages.  If,  therefore,  in  the  history 
of  an  individual  case  we  learn  that  the  periods  of  freedom 
from  suffering  have  become  by  degrees  shorter,  and  have 
finally  vanished,  we  may  often  predict  that  some  of  the 
conditions  named  are  present.  If,  in  addition,  there  are 
wasting  and  especially  anaemia,  we  may  be  very  suspicious 
of  the  onset  of  malignant  disease. 

Rehef  from  pain  is  obtained  not  only  from  food,  but 
from  alkalies,  sodium  carbonate,  "mint  drops,"  or  from 
vomiting.  Lavage  of  the  stomach  often  gives  great 
temporary  relief. 

The  fact  that  the  severity  of  the  pain  is  so  often 
mitigated  by  food  accounts  for  the  fact  that  many 
patients  do  not  lose  weight,  or  may  actually  gain  weight 
during  an  attack.  Patients  with  gastric  ulcer  recognize 
that  heavy  meals  three  times  a  day  bring  their  own 
punishment.  Lighter  meals  are  taken  at  shorter  intervals, 
and  the  total  amount  of  food,  much  of  it  of  high  value, 


CHRONIC  GASTRIC  ULCER  73 

is  accordingly  far  greater  than  that  usually  consiuned. 
Weight  is  therefore  gained. 

About  one-fifth  of  the  patients  who  are  found  to  have 
gastric  ulcers  complain  not  only  of  pain,  but  of  great 
prostration,  feebleness,  or  lassitude  coming  on  just  at  the 
time  when  the  pain  is  due.  On  close  enquiry  this  most 
distressing  symptom  may  be  found  to  have  preceded  the 
experience  of  pain  by  weeks  or  months.  The  periodicity 
of  the  two  is  identical. 

It  is  not  possible  to  emphasize  unduly  the  importance 
of  ascertaining  all  these  various  modifications  of  the  one 
symptom,  pain.  The  constancy  of  the  sequence — food, 
comfort,  pain ;  food,  comfort,  pain — ^is  the  most  important 
of  all  the  chnical  matters  concerned  with  the  diagnosis  of 
gastric  ulcer. 

The  next  symptom  in  point  of  frequency  is  vomiting. 
In  all  forms  of  ulceration  of  the  stomach  or  duodenum 
vomiting  is  an  inconspicuous  feature,  unless  obstruction 
has  developed  as  the  result  of  the  cicatrization  of  the 
ulcer.  Indeed,  a  degree  of  obstruction  which  is  by  no 
means  trivial  may  be  present,  and  yet  vomiting  is  very 
infrequent  or  entirely  absent.  It  is  no  uncommon  experi- 
ence to  hear  a  patient  say,  'T  never  vomit,"  and  for  an 
operation  to  disclose  an  extensive  ulcer  or  a  moderate 
degree  of  stenosis  in  the  body  or  near  the  pyloric  orifice 
of  the  stomach.  Patients  seem  to  have  a  great  capacity 
for  estimating  the  degree  of  tolerance  possessed  by  the 
stomach,  and  of  taking  only  such  foods,  or  foods  in  such 
measure,  as  will  arouse  no  resentment.  In  the  earfier 
stages  of  the  development  of  their  malady  vomiting  is  not 
seldom  self-induced  in  order  to  ease  the  stomach  of  a  heavy 
load,  and  a  sense  of  pressure  and  distension.  But  a  very 
little  experience  seems  to  teach  the  greater  number  of 


74  ESSAYS  ON  SURGICAL  SUBJECTS 

patients  the  quantity  of  food  that  is  appropriate  for  them. 
Thereafter  vomiting  occurs  quite  infrequently.  It  has 
probably  been  present  on  a  few  occasions  in  more  than 
half  the  number  of  patients  who  have  suffered  in  many 
attacks,  but  it  is  rare  to  find  that  quick  reference  is  made 
to  it  when  the  history  is  being  disclosed. 

When  in  the  record  of  any  patient  suffering  from 
"dyspepsia"  there  is  a  story  of  frequent  vomiting,  of  the 
inabihty  of  the  stomach  to  tolerate  the  presence  of  any 
foods,  of  even  fluid  nourishment  sparsely  taken  being  at 
once  rejected,  the  thought  that  gastric  ulcer  is  the  cause 
should  be  driven  from  one's  mind.  That  type  of  history, 
which  is  conmionly  heard,  is,  I  find,  rarely  present  in  cases 
of  organic  disease  of  the  stomach.  The  vomiting  due  to 
the  presence  of  an  ulcer  is  infrequent,  and  occurs  almost 
always  not  immediately  after  food,  but  after  a  shorter  or 
longer  interval.  The  meal  at  first  causes  rehef,  and  only 
after  that  period  of  relief  does  it  cause  disturbance. 

Hxmatemesis  also  occurs  far  less  conmionly  than  is 
supposed.  Haemorrhage  manifest  as  melaena,  or  in  the 
vomit,  is  recorded  in  less  than  25  per  cent,  of  my  cases;  in 
the  majority  of  these  the  amount  of  blood  lost  was  trivial, 
and  of  many  in  which  "haematemesis"  is  recorded  it  is  at 
least  doubtful  whether  blood  was,  in  truth,  present  I 
think  it  is  true  to  say  that  when  blood  is  discharged  from 
the  stomach  either  in  a  fresh  state  or  as  "black  vomit," 
it  is  conunonly  believed  that  a  chronic  ulcer  is  present. 
There  is  a  great  fallacy  in  such  opinions.  That  gastric 
haemorrhage  occurs,  and  occurs  profusely,  in  ulceration 
both  of  the  stomach  and  duodenum  is  certain;  but  the 
number  of  other  conditions  that  give  rise  to  haemorrhage 
is  so  large  that  the  possibihty  of  a  gastric  ulcer  being 
the  source  of  the  blood  should  not  be  strongly,  or  ex- 


CHRONIC  GASTRIC  ULCER  75 

clusively,  held.  I  have  so  often  seen  haemorrhage  of  the 
most  abundant  kind  ascribed  to  "gastric  ulcer"  which 
was  caused  by  such  other  conditions  as  splenic  anaemia, 
cirrhosis  of  the  liver,  appendicitis,  and  other  infective 
conditions  within  the  abdomen,  that  in  the  elucidation  of 
the  cause  of  such  a  condition  as  profuse  haematemesis  I 
seem  to  turn  to  other  possibihties  than  gastric  ulcer 
in  the  first  instance.  It  is  true  that  there  may  be  a 
confusion  as  to  terms  here.  For  when  a  patient  dies  of 
such  haemorrhage  a  very  close  examination  of  the  gastric 
mucosa  may  reveal  the  existence  of  tiny  chaps,  or  cracks, 
or  fissures  from  which  blood  has  certainly  issued.  And 
when  in  the  old  days  of  unwisdom  we  operated  upon 
such  patients  and  explored  the  cavity  of  the  stomach  the 
mucous  membrane  was  said  to  "weep  blood,"  Httle  trickles 
of  blood  could  be  seen  to  issue  from  many  points.  But 
these  little  gaps  in  the  mucosa  are  not  ulcers  of  the  kind 
that  produce  clinical  symptoms.  If  a  patient  has  suffered 
for  months  or  years  from  dyspepsia,  and  then  is  seized  with 
an  acute  attack  of  vomiting  and  haematemesis,  and  if 
an  operation  urgently  performed  reveals  the  condition 
of  the  mucosa  I  have  just  described,  it  is  the  worst 
of  fallacies  to  connect  the  dyspepsia  with  the  "ulcer" 
or  ulcers  then  supposed  to  be  present  in  the  stomach. 
The  ulcer  which  has  caused  repeated  attacks  of  in- 
digestion is  always  a  gross  lesion,  a  lesion  in  which  there 
are  present  not  only  the  evidences  of  destruction,  but 
also  of  defence;  around  the  crater  of  the  ulcer  is  an 
area,  greater  or  less,  of  inflammatory  action,  and  the 
serous  coat  of  the  stomach  is  plainly  involved.  If  the 
breaches  of  continuity  which  permit  the  escape  of  blood  in 
cases  of  cirrhosis  of  the  Hver,  splenic  anaemia,  and  the 
toxic  conditions  which,  as  a  rule,  have  their  origin  within 


76  ESSAYS  ON  SURGICAL  SUBJECTS 

the  abdomen,  are  called  "acute  ulcers,"  as  they  often  are, 
it  is  essential  to  remember  that  such  ulcers  are  recognizable 
by  no  other  clinical  evidence  than  haemorrhage,  or  in 
exceedingly  rare  instances  by  perforation;  they  are  never 
the  cause  of  a  continuing  or  recent  dyspepsia.  The  re- 
lation between  acute  ulcers  and  the  chronic  ulcer  which 
is  so  disabling  is  not  certain.  Dr.  Bolton,  whose  work  on 
Ulcer  of  the  Stomach  is  the  best  of  all  books  on  its  subject, 
beKeves  that  one  is  a  sequence  of  the  other.  He  is  prob- 
ably right.  Yet  the  acute  ulcer  as  such  gives  no  other 
clinical  indication  of  its  existence  than  haemorrhage  or  per- 
foration. The  diagnosis  of  "gastric  ulcer'*  in  these  cases 
of  grave  haemorrhage  was  held  to  be  confirmed  by  the 
after-history  and  the  results  of  medical  treatment.  The 
patients  regained  health  rapidly,  soon  lost  their  anaemia, 
and  were  able  to  take  food  without  restraint.  But  every- 
one who  has  considered  the  history  of  cases  in  which  there 
has  been  a  copious  haemorrhage  from  the  stomach  will 
agree  that  this  rebound  to  full  and  vigourous  health  is  quite 
conmaon.  It  is  so  even  in  cases  in  which  at  a  later  opera- 
tion a  frank  gastric  ulcer  is  seen. 

Such,  briefly  stated,  are  the  symptoms  of  gastric  ulcer. 
As  will  be  realized,  the  chief  dependence  in  making  a 
diagnosis  is  placed  upon  the  one  symptom — pain.  What 
are  the  other  methods  of  investigation  which  can  help 
us  to  a  decision?  Chief  among  them  I  now  place  the 
examination  of  the  stomach  after  a  barium  or  bismuth 
meal  by  x-rays.  In  this  work  I  have  rehed  upon  my 
colleague,  Mr.  Scargill,  and  I  am  greatly  indebted  to  him 
for  his  most  careful  and  accurate  work  and  for  the  skill 
which  he  shows  in  the  technical  sides  of  it.  His  methods, 
which  follow  closely  upon  those  of  R.  D.  Carman  of  the 
Mayo  Clinic,  show  that  the  possibility  of  making  an 


CHRONIC  GASTRIC  ULCER  77 

accurate  diagnosis  of  gastric  ulcer  is  greatly  increased 
by  the  x-ray  examination;  that,  indeed,  the  radiographic 
examination  alone  is  more  accurate  than  all  other  meth- 
ods combined,  and  that  a  diagnosis  which  is  proved 
by  subsequent  operations  to  be  correct  in  indicating  the 
presence  of  the  ulcer  or  in  demonstrating  its  size  and 
position  can  be  made  in  about  90  per  cent,  of  cases. 

The  following  is  his  method  of  examination:  After  a 
few  hours  of  fasting,  when  the  stomach  is  presumed  to 
be  empty,  a  bismuth  or  barimn  meal  of  thin  consistency 
is  given,  and  six  hours  later  the  first  examination  is  made. 
By  this  time  a  normal  stomach  is  able  to  empty  itself  of 
the  small  amount  of  opaque  food  administered.  If  a 
residue  is  seen,  there  is  a  delay  indicating  defective 
action.  A  second  similar  meal  is  now  given  and  the 
stomach  examined  forthwith.  The  radiographic  signs  of 
gastric  ulcer  are*: 

I.  Direct — The  ulcer  cavity  itself  is  demonstrated.  If 
an  ulcer  has  penetrated  into  the  walls  of  the  stomach,  or 
eroded  the  fiver  or  the  pancreas,  or  perforated  subacutely 
and  become  adherent  to  the  abdominal  waU,  the  crater  of 
the  ulcer  can  be  seen  fiUed  with  the  opaque  substance  of  a 
meal.  If  the  ulcer  is  near  the  lesser  curvature,  it  is 
visible  in  either  an  antero-posterior  or  semilateral  view. 
If  the  ulcer  is  on  the  posterior  smf  ace  the  best  view  is 
obtained  when  the  stomach  is  emptying.  An  ulcer  on  the 
anterior  or  posterior  surface  of  the  stomach  close  to  the 
pylorus  is  more  difficult  to  demonstrate. 

II.  Indirect. — In  the  majority  of  cases  of  gastric 
ulcer  a  very  remarkable  and  sustained  contraction  of 
the  circular  muscular  fibres  of  the  stomach  occurs  in 
or  near  the  segment  on  which  the  ulcer  Hes.    An  inden- 

*  For  full  details  the  work  of  Dr.  Carman  should  be  consulted. 


78  ESSAYS  ON  SURGICAL  SUBJECTS 

tation  of  the  greater  curvature,  of  varying  degree  and 
extent,  but  often  so  considerable  as  to  appear  almost  to 
bisect  the  stomach,  is  most  clearly  seen.  Its  appearance, 
whether  on  the  screen  or  on  a  photographic  plate,  is  re- 
markable. The  spasm,  in  the  majority  of  cases,  remains 
stationary  during  the  examination;  it  is  unaltered  by 
palpation,  massage,  or  by  the  administration  of  large 
quantities  of  belladonna.  It  relaxes  under  a  general 
anaesthetic,  and  is  not  seen  on  the  operation  table,  the 
stomach  wall  being  then  quite  soft  and  flaccid.  A  similar 
"incisura"  is  present  as  the  result  of  extrinsic  causes — 
causes  lying,  perhaps,  remote  from  the  stomach.  The 
commonest  excitants  are  duodenal  ulcer,  infection  of  the 
gall-bladder,  with  or  without  stones,  and  chronic  appen- 
dicitis. The  spasm  due  to  these  causes  is  variable  in  posi- 
tion and  duration,  is  modified  by  massage  or  pressure,  and 
relaxes  almost  always  after  the  administration  of  atropin 
given  in  an  amount  which  produces  a  physiological  re- 
sponse. It  is  also  inconstant,  present  on  one  occasion, 
absent  on  another,  and  changes  capriciously. 

The  presence  of  the  persistent  spasm  is  strong  pre- 
sumptive evidence  of  the  existence  of  an  ulcer;  the 
presence  of  an  "incisura"  on  the  greater  curvature,  with 
a  *'bud-like"  opaque  projection  on  the  lesser  curvature, 
is  an  unequivocal  evidence;  in  every  such  case  an  ulcer 
is  present. 

The  radiographic  method  is  the  one  certain  method 
of  diagnosis,  and  is  now  an  indispensable  addition  to  the 
older  and  far  less  accurate  procedures. 

Of  the  chemical  examination  of  the  stomach  contents 
I  do  not  speak  with  any  enthusiasm.  For  several  years 
my  patients  were  submitted  to  this  form  of  investigation, 
but  I  cannot  think  that  the  evidence  thereby  obtained 


Fig.  1. — Very  small  "niche"  type  of  ulcer  on  lesser  curvature.    Involves  stomach 
wall  only.     No  incisura  seen  in  this  case.     Wire  marks  costal  margin. 


Fig.  2. — IJker  crater  on  lesser  curvature  penetrating  into  lesser  omentum.    V\  ell- 
marked  incisura  on  the  greater  curvature,  almost  bisecting  the  stomach. 


Fig.  3. — ^Ulcer  crater  on  lesser  curvature  penetrating  lesser  omentum  and  ad- 
herent to  left  lobe  of  liver.     Well-marked  incisura. 


Fig.  4. — ^Ulcer  crater  on  lesser  curvature.    Incisura  in  this  case  is  a  little  above 
the  level  of  the  ulcer. 


Fig.  5. — Ulcer  crater  on  posterior  surface  near  lesser  curvature,  only  seen  when 
stomach  was  almost  empty.     At  operation  foimd  adherent  to  pancreas. 


Fig.   6. — Hugo  ulcer  cavity  on  lesser  curvature  penetrating  left  lobe  of  liver. 
The  cavity  was  nearly  85  inches  long. 


Fig.  7. — Groove-like  ulcer  on  the  lesser  curvature  1^  inches  long.    Very  well- 
market!  spasmodic  hour-glass  contraction.     No  hour-glass  at  operation. 


Fig.  8. — Ulcer  crater  on  lesser  curvature  with  w ell-marked  incisure.    (Dr.  G.  W. 

Watson's  case.) 


CHRONIC  GASTRIC  ULCER  79 

enabled  a  greater  accuracy  to  attach  to  the  diagnosis  or 
justified  the  increased  trouble  it  gave  to  them.  Hyper- 
chlorhydria  is  present  in  so  many  other  diseases  than 
gastric  or  duodenal  ulcer  that  its  presence  does  not  offer 
positive  or  even  contributory  evidence  of  any  real  value. 
In  rather  over  40  per  cent,  of  the  total  number  of  cases  in 
which  an  ulcer  is  present  there  is  no  hyperchlorhydria,  and 
in  a  small  number,  estimated  at  from  10  to  20  per  cent., 
there  is  a  reduction  in  the  gastric  acidity.  For  reasons 
connected  with  the  war  I  have  rarely  submitted  patients 
to  this  form  of  inquiry  in  the  last  four  years,  but  it  will  be 
interesting  to  discover  the  relationship,  if  any,  between  the 
degree  of  gastric  acidity  and  the  quality  and  duration  of 
the  gastric  spasm  due  to  extrinsic  as  well  as  intrinsic 
causes. 

Physical  examination,  in  the  absence  of  obstruction  in 
the  body,  or  at  the  outlet  of  the  stomach,  reveals  very 
little.  There  is  a  record  of  tenderness  in  the  epigastrium 
in  almost  every  one  of  the  patients  who  are  subsequently 
found  to  have  an  ulcer  in  the  stomach.  In  ulcers  of  the 
lesser  curvature  I  have  sometimes  found  great  tenderness 
high  up  on  the  left  along  the  costal  margin — tenderness 
which  becomes  more  acute  when  the  patient  breathes 
deeply.  The  kind  of  sensitiveness  is  then  present  on  the 
left  side  which  on  the  right  estabhshes  "Murphy's  sign." 
The  signs  in  pyloric  obstruction  and  in  hour-glass  stomach 
are,  of  course,  well  known. 

If  all  the  methods  of  examination  are  strictly  brought 
to  bear  upon  the  cases  commonly  referred  to  as  those  of 
"gastric  ulcer"  it  will  be  found  that  in  a  majority  the 
diagnosis  cannot  be  upheld.  The  diagnosis  of  gastric 
ulcer  is  loosely  and  inaccurately  made;  a  host  of  other 
diseases,  functional  and  organic  ahke,  are  so  described, 


80  ESSAYS  ON  SURGICAL  SUBJECTS 

and  in  consequence  the  belief  is  widely  held  that  "gastric 
ulcer"  is  a  conunon  disease.  It  would  be  more  accurate 
to  call  it  a  rare  disease.  Over  a  series  of  years  I  find  that 
for  every  gastric  ulcer  seen  on  the  operation  table,  there 
are  four  or  five  duodenal  ulcers,  and  five  to  six  cases  of 
cholehthiasis.  A  gastric  ulcer  is  by  no  means  easy  to 
recognize  even  after  the  most  scrupulous  inquiry  and  ex- 
amination. More  mistakes  are  made  in  the  diagnosis  of 
gastric  ulcer  than  is  the  case  in  any  other  abdominal 
disorder. 

It  must  now  be  generally  recognized  that  many  of  the 
diseases  arising  in  connexion  with  the  abdominal  viscera 
are,  for  months  or  years,  looked  upon  as  cases  of  gastric 
disorder.  I  pointed  this  out  a  few  years  ago  in  two  papers 
published  in  the  British  Medical  Journal  (October 
18th,  1907,  "Pathology  of  the  Hving,"  and  November  28th, 
1908,  "Inaugural  Symptoms").  Up  to  the  time  of  the 
pubHcation  of  these  articles  it  had  not  been  recognized 
that  in  cholehthiasis,  for  example,  all  the  prodromal  symp- 
toms were  attributed  to  defects  in  the  stomach,  and  the 
medicaments  administered  were  in  consequence  those  used 
in  gastric  diseases.  The  same  statement  holds  good  with 
regard  to  chronic  disease  in  the  appendix,  in  the  small 
or  in  the  large  intestine.  We  are  now  feimihar,  as  the 
result  of  x-ray  examination  and  of  the  chemical  exami- 
nation of  the  gastric  contents,  with  the  truth  that  all  these 
conditions  express  themselves  in  terms  of  gastric  disturb- 
ance, of  hypersecretion,  and  of  spasm.  And  at  the  time 
when  operations  are  performed  we  can  discover  by 
inspection  of  the  stomach  such  conditions  as  enable  one 
to  predict  that  a  lesion  will  be  found  on  closer  manual 
examination  not  in  the  stomach,  but  in  the  appendix  or  its 
neighbourhood. 


CHRONIC  GASTRIC  ULCER  8i 

If,  for  example,  a  patient  has  had  a  type  of  dyspepsia 
which  has  led  to  a  diagnosis  of  gastric  ulcer  and  an  opera- 
tion is  performed,  the  stomach  may  show  no  scar,  nor  can 
any  examination,  however  careful,  display  the  ulcer  whose 
presence  was  predicted.  If,  however,  the  stomach  is 
closely  inspected  before  it  is  handled  the  following  con- 
ditions may  be  seen:  The  pyloric  part  of  the  stomach  is 
decidedly  redder  than  natural — there  is  a  "pyloric  blush." 
That  part  of  the  stomach  is  soon  observed  to  contract 
eagerly  and  vigorously ;  sometimes  the  spasm  is  so  severe 
and  so  prolonged  that  there  may  be  a  suspicion  of  a  tu- 
mour, but  by  degrees  the  spasm  relaxes,  and  the  parts  be- 
come supple  again.  The  spasm  may  be  irregular,  now  at 
one  part,  now  at  another;  now  slow  and  deliberate,  now 
fugitive.  Along  the  greater  curvature  the  glands  are 
enlarged.  When  these  three  conditions  are  seen  the 
prophecy  may  be  confidently  made  that  the  stomach  is 
healthy  and  that  the  appendix  (or  one  of  its  neighbours  in 
the  alimentary  canal)  is  diseased.  In  such  cases  gastro- 
enterostomy has  often  been  performed,  sometimes,  it  is 
curious  to  note,  with  benefit,  but  as  a  rule  with  disastrous 
eflfects.  It  has  been  my  lot  to  perform  a  secondary  opera- 
tion upon  many  such  patients,  and  to  remove  a  badly 
diseased  appendix  or  to  resect  a  tuberculous  intestine,  and 
perhaps  to  undo  the  anastomosis  which  should  never 
have  been  made.  The  work  of  Cole,  Barclay,  Carman, 
and  others  explains  quite  clearly  how  it  comes  about  that 
these  intestinal  disorders  affect  the  stomach  and  cause  its 
musculature  to  contract  in  the  irregular  and  painful  man- 
ner which  raises  the  suspicion,  or  seems  to  make  certain 
the  opinion,  that  an  ulcer  is  present.  But  there  is  also 
the  infective  element  in  such  cases,  as  Wilkie  has  shown 
experimentally,  and  it  is  the  toxaemia  which  is  its  outcome 

6 


82  ESSAYS  ON  SURGICAL  SUBJECTS 

that  leads,  as  Spencer  and  Hutchinson  have  shown,  to 
profuse  haemorrhages  from  the  stomach. 

The  stomach  is  an  organ  full  of  sympathy  for  other 
sufferers.  Hardly  any  of  the  viscera  connected  with  the 
intestine,  or  the  bowel  itself,  can  be  affected  without  the 
stomach  playing  its  part  in  the  disturbance  also.  This 
ii  does  by  pouring  out  an  excess  of  secretion,  and  by 
tumultuous  and  irregular  activities.  It  speaks  so  loudly 
that  its  voice  only  is  heard. 

The  whole  subject  now  briefly  mentioned  requires  close 
and  prolonged  investigation.  We  must  seek  to  find  out 
as  accurately  as  possible  the  chnical  indication  that  will 
lead  us  to  diagnose  a  veritable  lesion  of  the  stomach  in 
certain  cases,  and  in  others  to  be  able  confidently  to  say 
that  the  stomach  is  intact,  and  that  other  organs  are 
teUing  the  story  of  their  own  disease  in  terms  of  stomach 
discomfort. 

Differential  Diagnosis 

The  very  great  difficulties  in  the  diagnosis  of  gastric 
ulcer  are  due  to  reasons  which  we  can  now  fully  appreciate. 
An  ulcer  of  the  stomach  does  not  arouse  symptoms  merely 
because  of  the  gap  in  one  or  more  of  the  several  layers  of 
the  stomach.  We  may  be  certain  of  this  because,  after  an 
"attack"  of  gastric  ulcer  is  over,  and  the  patient  is  wholly 
free  from  symptoms,  an  operation  may  disclose  the  open 
crater  of  an  ulcer  large  or  small.  The  exact  cause  of  the 
symptoms  is  uncertain,  but,  so  far  as  we  know  at  present, 
other  conditions,  in  addition  to  the  structural  defect,  must 
be  present  befOTe  the  symptoms  appear.    These  are: 

I.  Evidences  of  infection  around  the  ulcer,  such  as 
induration,  local  peritonitis,  the  deposit  of  fat  in  and 
around  the  base  of  the  ulcer,  and  enlargement  of  neigh- 


CHRONIC  GASTRIC  ULCER  83 

boirring  glands.    The  "sentinel  gland"  of  Lund  is  constant 
in  cases  of  active  ulceration. 

II.  Spasm  of  the  musculature  of  the  stomach.  Of  the 
presence,  severity,  and  duration  of  this  condition  we  had 
very  little  knowledge  until  the  methods  of  examination  by 
x-ray  became  perfected,  chiefly  by  R.  D.  Carman.  We 
now  know  that  a  high  degree  of  spasm  is  present  and 
constant  in  examples  of  ulcer  bf  the  stomach,  and  present, 
though  inconstant  and  variable,  in  those  cases  where  there 
is  no  primary  lesion  in  the  stomach. 

III.  An  increase  in  the  acidity  of  the  gastric  juice. 
This  hyperacidity  is  by  no  means  constant  either  in 
gastric  or  in  duodenal  ulcer,  but  it  is  possibly  a  factor  of 
importance  in  the  awakening  of  symptoms. 

These  three  conditions — infection,  locahzed  spasm  of 
the  gastric  muscle,  and  hyperacidity — are  all  present  not 
only  in  true  ulcer  of  the  stomach  but  also,  in  varying 
degrees,  in  most  of  those  distant  conditions  which  are  able 
to  arouse  a  gastric  reflex;  and  it  is  their  presence  which 
causes  that  mimicry  of  the  symptoms  of  gastric  ulcer  by 
other  lesions  which  may  be  so  exact  as  to  deceive  the 
most  expert  enquirer.  My  own  strong  feehng  is  that  in 
order  to  obtain  precision  where  so  much  has  been  vague, 
no  diagnosis  of  chronic  ulcer  should  now  be  confidently 
accepted  unless  the  ulcer  is  diagnosed  by  aj-ray  examina- 
tion or  is  displayed  upon  the  operation  table. 

The  diagnosis  of  gastric  ulcer  from  a  study  of  the 
chnical  and  chemical  evidences  alone  is  so  uncertain;  the 
various  methods  of  treatment  associated  with  the  names 
of  Lenhartz,  Leube,  Cohnheim,  Bolton,  Sippy,  and  others, 
so  helpful  in  all  cases  of  infection  of  the  alimentary  canal, 
and  the  physical  repose  which  accompanies  the  treatment 
so  weighty  an  influence  for  good,  that  no  certain  con- 


8U  ESSAYS  ON  SURGICAL  SUBJECTS 

elusions  can  be  drawn  from  even  a  long  series  of  cases. 
In  order  to  allow  of  an  acciu'ate  judgement  to  be  made 
of  the  value  of  any  form  of  medical  treatment  we  must 
be  certain,  in  the  first  place,  that  a  real  gastric  ulcer  is 
present.  The  concurrence  of  the  radiographer  and  the 
surgeon  in  the  diagnosis  is  necessary.  The  mere  expres- 
sion of  an  opinion,  however  confident,  by  a  physician, 
however  distinguished,  in  the  absence  of  this  confirma- 
tion, is  for  scientific  purposes  entirely  without  value. 
When  the  diagnosis  is  assiu'ed  and  accepted,  then  med- 
ic£j  treatment  may  be  carried  out  and  its  results  exam- 
ined. The  radiographer  should  follow  the  treatment, 
examining  with  the  x-ray  say  once  a  month  to  discover 
the  changes  which  have  taken  place,  and  in  the  end  to 
assert  that  heahng  has,  or  has  not,  taken  place. 

The  tempor£uy^  absence  of  symptoms,  as  the  surgeon 
knows  weU  enough,  by  no  means  indicates  that  the  ulcer 
is  healed.  If  it  is  not  healed  the  radiographer  will  recog- 
nize the  fact  at  once.  There  is  urgent  need  of  some 
accurate  knowledge  upon  these  matters;  at  present  we 
have  little  or  none. 

How  great  the  difficulty  in  diagnosis  really  is  could 
not  be  better  shown  than  by  a  study  of  those  cases  in 
which  the  patients  have  been  given  over  to  the  care 
of  the  surgeon  for  treatment,  and  in  which  the  operation 
of  gastro-enterostomy  has  been  performed  without  ben- 
efit. There  was  a  time  when  this  operation  was  held 
to  be  the  certain  cure  for  ulcer  of  the  stomach.  If  its 
"mechanical"  virtues  were  not  urgently  needed  because 
of  the  obstruction  caused  by  the  ulcer,  its  "physiological" 
eflfects  at  least  would  be  salutary.  A  fist  of  the  diseases 
called  "gastric  ulcer"  by  careful  medical  men,  often 
after  consultation  with  others,  and  treated  by  operation, 


CHRONIC  GASTRIC  ULCER  85 

was  considered  by  me  in  a  paper  in  the  British  Medical 
Journal  (July  12th,  1919).  It  is  humiliating  and  heart- 
breaking to  ponder  over  the  mistakes  in  diagnosis  which 
come  to  hght  in  the  records  which  were  considered  during 
the  preparation  of  that  article.  In  many  of  these  cases  a 
diagnoses  of  gastric  ulcer  had  been  made  on  evidence 
that  was  considered  adequate  by  careful  practitioners. 
We  cannot  rid  the  matter  of  error  imtil  we  realize  how 
very  difficult  the  diagnosis  of  gastric  ulcer  really  is,  and 
until  we  decide  that,  no  matter  how  confident  the  clinical 
diagnosis  may  be  before  operation,  it  shall  not  guide 
us  during  the  operation  too  firmly.  It  is  many  years 
since  I  decided  for  myself  that  no  gastric  or  duodenal 
ulcer  existed  unless  it  could  be  seen,  felt,  and  demon- 
strated to  a  sceptical  onlooker.  It  will  help  to  a  better 
understanding  of  the  whole  most  difficult  subject  if  in 
future  no  diagnosis  of  gastric  ulcer  is  accepted,  as  a 
basis  for  treatment,  unless  the  presence  of  the  ulcer  is 
made  certain  by  a;-ray  examination  or  by  operation.  To 
accept  the  clinical  diagnosis  of  gastric  ulcer  and  to  perform 
any  operation  upon  the  stomach  without  most  clearly 
recognizing  the  ulcer  is  to  court  disaster.  If  the  mistakes 
in  diagnosis  to  which  I  have  referred  had  been  followed 
by  medical  rather  than  by  surgical  treatment,  what  would 
be  the  value  of  the  experience  derived  from  the  cases  in 
deciding  upon  the  effect  of  similar  treatment  in  veritable 
cases  of  ulcer?  The  truth  is  that  we  cannot  state  in  terms 
of  accuracy  the  results  of  medical  treatment  of  gastric 
ulcer  imless  and  until  we  are  certain  that  an  ulcer  has 
been  present.  And,  as  I  have  said,  the  clinicgJ  evidences 
alone  are  very  fallacious. 


86  ESSAYS  ON  SURGICAL  SUBJECTS 

The  Treatment  of  Chronic  Gastric  Ulcer 
A.  Medical  Treatment 

I  hope  we  may  now  agree  that  the  results  of  the  treat- 
ment of  gastric  ulcer  by  any  of  the  systems  already 
mentioned,  or  by  any  dietary  or  medicinal  regimen,  are 
vitiated  by  the  lack  of  accuracy  in  the  diagnosis  of  gastric 
ulcer.  The  most  popular  of  all  methods  is  that  introduced 
by  Sippy,  which  would  appear  to  meet  more  combatantly 
those  conditions  in  the  stomach  which  he  beheves  must  be 
controlled  before  an  ulcer  can  have  the  chance  to  heal.  It 
is  based  upon  the  wide-spread  behef  (is  it  anything  more?) 
that  the  reduction  of  the  acid  in  the  stomach  is  the  first 
necessity.  This  is  att£iined  by  dilution  of  food,  alkaUniza- 
tion  of  the  gastric  contents  every  hour,  by  the  adminis- 
tration of  fats,  and  by  lavage. 

The  questions  which  in  this  connexion  require  answer 
are: 

1.  Does   a   chronic   gastric   ulcer   ever   heal   under 

medical  treatment? 

2.  Does  it  long  remain  healed? 

3.  Does  it  heal  without  producing  such  conditions  as 

need  surgical  treatment  for  their  rehef ? 
1.  Chronic  gastric  ulcers  probably  heal  sometimes 
under  treatment,  or  after  the  exercise  of  continued  care 
in  diet.  The  scars  left  by  their  heahng  are  seen,  though 
very  rarely,  in  the  post-mortem  room  and,  still  more  in- 
frequently, in  the  operation  theatre.  The  discrepancy 
between  the  reputed  frequency  of  gastric  ulcer  and  the 
scarcity  of  the  scars  found  in  the  dead-house  has  not 
attracted  adequate  attention.  The  number  of  healed 
cicatrices  found  in  the  operation  theatre,  when  the  stom- 
ach is  examined  as  a  routine  in  almost  all  operations,  is 


CHRONIC  GASTRIC  ULCER  87 

exceedingly  small.  This  may  be  due  to  the  rarity  with 
which  sound  healing  occurs,  or  to  the  tendency  of  healed 
ulcers  to  break  out  afresh.  All  the  available  evidence 
strongly  supports  the  opinion  that  the  firm  heahng  of  a 
chronic  gastric  ulcer  is  a  very  unusual  occurrence. 

2.  Do  ulcers  when  healed  long  remain  so?  In  the 
majority  of  cases  the  answer  must  be  No.  The  character- 
istic quality  in  the  symptoms  of  gastric  ulcer  is  recurrence. 
There  is  a  succession  of  "attacks,"  of  changing  severity 
and  of  variable  length.  The  tendency,  on  the  whole,  is 
towards  more  serious  attacks  with  briefer  intervals.  It  is 
not  by  any  means  certain  that  an  interval  in  which  there 
is  freedom  from  suffering  means  that  the  ulcer  is  healed. 
In  hour-glass  stomach,  where  a  considerable  degree 
of  contraction  has  occurred  in  the  body  of  the  organ, 
it  is  a  matter  of  great  rarity  to  find  that  the  ulcer  is 
soundly  healed. 

3.  When  a  gastric  ulcer  of  moderate  or  large  size  heals 
there  is  inevitably  some  degree  of  contraction.  In  this 
way  hour-glass  stomachs  are  produced,  and  stenosis  near 
the  pylorus.  We  cannot  say  with  what  frequency  the 
successful  medical  treatment  of  a  chronic  gastric  ulcer 
produces  the  conditions  which  need  surgical  reUef,  but  it 
is  certainly  not  seldom,  for  any  large  scar  wherever 
placed,  and  especially  if  it  has  contracted  adhesions  to 
neighbouring  parts,  must  embarrass  the  action  of  the 
stomach,  or  cause  distress  after  food.  Notwithstanding 
any  or  all  of  these  considerations,  a  really  serious  attempt 
to  treat  all  cases  of  chronic  gastric  ulcer  by  medical  treat- 
ment should  be  made.  It  is  best  to  have  no  half-measures. 
It  is  at  least  arguable  that  the  necessity  for  surgical  rehef 
in  many  patients  is  due  to  a  too  perfunctory  trial  of 
medical  treatment  in  the  earlier  attacks.    The  hospitaj 


88  ESSAYS  ON  SURGICAL  SUBJECTS 

accommodation  in  the  country  is  too  small  to  allow  of  the 
poorer  classes  receiving  the  rest  and  supervision  that  is 
necessary.  The  pressure  on  beds  is  too  heavy.  The  ideal 
would  be  to  keep  the  patient  under  treatment  until  an 
x-ray  examination  showed  that  the  ulcer  was  healed. 

B.  Surgical  Treatment 

In  discussing  the  surgical  treatment  of  gastric  ulcer  the 
first  matter  for  consideration  relates  to  the  importance 
of  discovering  any  sources  of  still  continuing  infection 
which  may  first  have  led  to  the  development  of  the  ulcer. 
The  primary  infection  cannot  always  be  discovered — 
indeed,  cannot  often  be  locaHzed  with  certainty — but  it  is 
a  fair  assumption  to  make  that  any  chronic  infection  of 
which  the  evidences  are  still  discoverable  may  have  acted 
as  a  cause  of  the  original  ulcer,  or  have  provoked  a  re- 
currence of  it  in  one  or  more  of  those  attacks  which  are  a 
characteristic  feature  of  the  cHnical  history.  The  causal 
infection  may  not  be  found  until  the  abdomen  is  opened, 
for  in  my  view  a  large  number  of  the  cases  of  gastric  ulcer 
upon  which  the  surgeon  must  operate  are  secondary  to 
an  infection  arising  in  some  part  of  the  intestinal  canal, 
more  especially  in  the  appendix.  But  there  are  not  a 
few  cases  in  which  the  infective  agent  appears  to  reach 
the  stomach  by  way  of  the  mouth.  Disease  of  the 
teeth  or  gimis,  of  the  antrum  or  other  accessory  sinuses, 
or  of  the  nasopharynx,  have  all  been  found  in  cases  upon 
which  I  was  asked  to  operate.  If  in  any  such  case  the 
lesion  is  a  gross  one,  and  likely  long  to  continue,  it  is  most 
necessary  that  it  should  be  dealt  with  before  any  operation 
upon  the  ulcer  itself  is  undertaken.  If  constant  search  is 
made  for  a  diseased  fang,  alveolar  abscesses,  and  septic 
conditions  in  the  upper  part  of  the  pharynx  or  air  passages, 


CHRONIC  GASTRIC  ULCER  89 

the  evidence  of  serious  disease,  requiring  radical  treat- 
ment, will  be  discovered  far  more  frequently  than  is 
generally  beheved.  One  method  of  inquiry  worth  pur- 
suing is  the  investigation  by  x-ray  of  the  alveolar  proc- 
esses in  all  patients  to  whom  a  barium  meal  is  to  be 
given  preparatory  to  a  screen  examination  of  the  stomach. 
One  of  the  factors  most  certainly  causing  a  recurrence  of 
ulceration  in  the  stomach,  or  of  ulceration  at  or  near  the 
suture  line  after  gastro-enterostomy  has  been  performed, 
is  infection  derived  from  one  or  other  of  the  several  sources 
here  indicated. 

The  necessity  for  the  surgical  treatment  of  a  gastric 
ulcer  is  a  confession  that  medical  treatment  has  failed. 
As  conomonly  employed,  it  is  doomed  to  failure.  It  too 
often  consists  in  the  mere  administration  of  a  bismuth 
mixture  when  the  sufferer  is  treated  in  the  out-patient 
department  of  a  large  hospital.  There  is  not  anything 
approaching  the  necessary  accommodation  in  hospitals  in 
this  country  for  the  patients  suffering  from  gastric  or 
duodenal  ulcers,  whose  successful  treatment  by  medical 
means  necessitates  that  constant,  watchful  supervision 
of  every  detail  which  hospital  treatment  alone  affords. 
A  successful  operation  upon  a  patient  suffering  from 
gastric  or  duodenal  ulceration  will  depend  in  part  upon 
careful  and  adequate  preparation.  Not  a  few  of  the 
patients  are  weakly,  ill-nourished,  and  of  a  low  resisting 
power  when  first  they  come  under  our  care.  By  keeping 
them  at  rest  for  a  few  days,  giving  them  large  quantities 
of  fluid  by  the  mouth,  or  by  rectum,  or  subcutaneously; 
by  the  administration  in  such  fluid  of  sodium  carbonate 
or  glucose;  or  occasionally  by  performing  a  direct  trans- 
fusion of  blood,  their  condition  can  be  greatly  benefited, 
and  the  risks  of  operation  correspondingly  reduced.    The 


90  ESSAYS  ON  SURGICAL  SUBJECTS 

practise  of  withholding  fluids  for  a  few  hours  before 
operation  is  always,  I  think,  a  procedure  of  very  question- 
able value;  in  patients  reduced  in  strength  by  lack  of 
nourishment,  or  by  pain  extending  over  long  periods,  it  is 
positively  a  factor  pregnant  with  harm.  When  the  opera- 
tion is  performed  the  choice  in  exceptional  circumstances 
of  hedonal  as  an  anaesthetic  is  very  helpful.  The  anaes- 
thesia is  quietly  induced,  lasts  long,  gives  remarkable 
relaixation  of  the  abdominal  wall,  and  provides  two  or 
three  pints  of  fluid  at  a  time  when  fluid  is  much  needed. 
The  surgical  treatment  of  a  chronic  gastric  ulcer*  may 
call  for  the  performance  of  one  or  other  of  the  foUowing 
operations: 

I.  Gastxo-enterostomy, 
II.  Excision. 
III.  Gastxo-enterostomy  combined  with  excision  by  knife  or  by  cautery 

(Balfour's  operation). 
rV.  Gastro-enterostomy  combined  with  jejunostomy  (Moynihan). 
V.  Resection  of  a  part  of  the  body  of  the  stomach — "sleeve  resection." 
VI.  Partial  gastrectomy. 

I.  Gastro-enterostomy 

The  operation  which  has  been  the  most  frequently 
practised  in  the  past,  and  is  still  that  preferred  by  many 
operators,  is  gastro-enterostomy.  The  operation  was  first 
practised  on  September  27th,  1881,  by  Wolfler  in  Vienna. 
He  was  dealing  with  a  case  in  which  carcinoma  of  the 
pyloric  part  of  the  stomach  was  causing  obstruction,  and 
the  intention  was  to  remove  the  growth  by  one  of  the 
methods  recently  introduced  by  his  master,  Billroth. 
Owing  to  the  presence  of  secondary  deposits  and  the 
fixity  of  the  tumour,  resection  was  impossible,  and  the 
abdomen  was  about  to  be  closed  when  Nicoladoni,  acting 

*  Discussion  of  the  treatment  of  the  acute  perforation  of  a  chronic  gastric 
ulcer  is  omitted  from  this  paper. 


CHRONIC  GASTRIC  ULCER  91 

as  assistant,  suggested  that  the  obstruction  might  be 
relieved  by  making  an  opening  between  the  stomach  and 
the  small  intestine.  The  success  in  this,  and  in  many 
similar  cases,  was  an  event  of  great  significance,  and  one 
of  the  most  important  landmarks  in  the  history  of  ab- 
dominal surgery.  It  was  not  long  before  examples  of 
pyloric  stenosis  due  to  the  healing  of  a  simple  ulcer  were 
treated  by  the  same  method.  What  happened  is  known 
to  all  the  world.  Patients  who  had  suffered  for  years  from 
the  miseries  of  the  confirmed  dyspeptic,  who  finally  had 
the  extreme  discomforts  caused  by  the  recurrent  vomiting 
of  the  stagnant  and  fermenting  contents  of  the  stomach, 
who  Hved  on  the  most  restricted  diet  in  order  that  their 
sufferings  might  be  lessened,  were  suddenly  restored  to 
vigourous  health,  were  able  to  satisfy,  without  appre- 
hension or  unhappy  consequences,  their  keen  appetites; 
rapidly  gained  health  and  happiness,  and  added  con- 
siderably to  their  weight.  No  operation  in  surgery  had 
ever  produced  more  striking  or  swifter  results.  Owing 
largely  to  the  advocacy  and  the  successful  w  ork  of  Doyen, 
the  operation  began  to  be  practised  in  cases  of  ulcer  oc- 
curring in  the  body  of  the  stomach,  cases  in  which  no 
obstruction  was  caused  either  by  the  open  ulcer  or  by  the 
stenosis  resulting  from  its  partial  cicatrization. 

Results  by  no  means  so  happy  were  soon  witnessed,  and 
in  cases  whose  number  seemed  quickly  to  mount  up  the 
ultimate  consequences  of  the  operation  were  disastrous. 
There  were  several  reasons  for  this.  The  chief,  perhaps, 
was  the  inaccuracy  of  the  diagnosis  in  many  instances. 
It  was  not  then,  it  is  not  now,  sufiiciently  realized  that  the 
diagnosis  of  gastric  ulcer  is  difiicult  and  that  the  disease 
is  rare.  The  operation  came  to  be  practised  for  "chronic 
dyspepsia,"  and  many  of  the  Httle  splashes  of  thick  lymph 


92  ESSAYS  ON  SURGICAL  SUBJECTS 

so  often  seen  on  the  under  surface  of  the  transverse  meso- 
colon, adherent  to  the  posterior  wall  of  the  stomach,  were 
assumed  to  be  the  scars  of  gastric  ulcers  which  had  healed. 
And  so  in  many  cases  when  the  stomach  was  normal, 
where  the  lesion  causing  the  symptoms  lay  elsewhere,  the 
short-circuiting  operation  was  performed,  with  unhappy 
consequences.  Another  reason  for  the  disasters  following 
upon  operation  was  a  technical  one.  The  anastomosis 
was  made  with  a  long  proximal  loop,  which,  emptying  with 
increasing  diflficulty,  became  waterlogged;  or  adhesions 
obstructed  the  efferent  jejunum;  or  the  opening  into  the 
stomach  was  badly  placed.  From  one  or  other  cause 
such  difficulties  as  regurgitant  vomiting  were  frequently 
seen.  Further  reasons  were  found  in  the  inabihty  of  the 
ulcer  to  heal  even  after  gastro-enterostomy  had  been  per- 
fectly performed  in  an  appropriate  case,  and  in  the  later 
development  of  cancer  of  the  stomach,  presumably  upon 
the  base  of  an  unclosed  ulcer. 

A  few  years  ago  a  revision  of  my  own  cases  in  which 
a  gastric  ulcer  had  been  clearly  demonstrated  showed  that 
the  results  could  be  classified  into  three  groups. 

1.  The  Results  were  Excellent — ^With  the  same  alacrity 
that  is  witnessed  in  cases  of  duodenal  ulcer,  or  in  cases  of 
pyloric  stenosis,  the  patient  lost  edl  discomforts,  and  made 
a  speedy  and  excellent  return  to  health.  I  had  not  then 
in  all  cases  indicated  in  a  diagram,  made  immediately  after 
the  operation  as  I  do  now,  the  exact  position  and  the 
approximate  size  of  the  ulcer;  and  therefore  I  am  not  able 
.  to  say  exactly  what  the  condition  of  the  stomach  was  in 
this  group  of  cases.  But  in  many  cases  it  is  certain  that 
the  ulcer  was  near  the  pylorus;  that  the  gastro-enteros- 
tomy opening  was  on  the  proximal  side  of  it.  In  others 
the  ulcer  was  on  the  lesser  curvature  and  was  small, 


CHRONIC  GASTRIC  ULCER  93 

and  free  from  adhesions.  It  had  not,  that  is  to  say, 
perforated  the  coats  of  the  stomach  to  become  adherent  to 
the  abdominal  wall,  hver,  or  pancreas. 

2.  The  Results  were  Indifferent. — Some  patients  were 
found  to  have  improved,  in  many  cases  for  periods  of 
months  or  years,  others  were  known  to  have  relapsed.  At 
a  subsequent  operation  the  ulcer  was  found  to  be  still 
present;  it  was  then  removed  by  local  excision  by  the 
cautery,  or  by  the  performance  of  the  operation  of  partial 
gastrectomy. 

3.  The  Results  were  Bad. — In  this  class  of  cases 
malignant  disease  developed  in  the  base  of  the  ulcer, 
and  so  near  the  ulcer  as  to  make  differentiation  im- 
possible. The  question  of  the  degeneracy  of  a  simple 
ulcer  into  a  mahgnant  one  is  still  warmly  debated,  and 
there  is  no  approach  to  an  agreement  between  the  several 
authorities.  The  evidence  considered  by  the  protagonists 
on  either  side  is  clinical  and  pathological. 

In  more  than  half  the  cases  of  carcinoma  of  the  stomach 
treated  by  operation  there  is  a  history  suggestive  of  the 
previous  existence  and  of  the  recurrence  of  a  gastric  ulcer. 
No  one  is  more  ready  than  I  am  to  admit  that  such  a 
history  is  not  a  full  warrant  for  asserting  that  an  ulcer 
has  been  present.  For  on  the  clinical  evidences  alone 
a  diagnosis  of  gastric  ulcer,  however  confidently  made, 
cannot  always  be  upheld.  The  only  certain  evidence 
obtained  before  operation  is  afforded  by  a  radiological 
examination,  and  I  do  not  know  of  any  case  in  which 
a  diagnosis  of  gastric  ulcer  has  been  positively  made  with 
this  and  other  methods  in  which  carcinoma  was  subse- 
quently found.  The  cUnical  evidences,  therefore,  how- 
ever strongly  suggestive,  are  not  positive  proof.  In  about 
25  to  30  per  cent,  of  the  cases  of  carcinoma  of  the  stomach 


P4  ESSAYS  ON  SURGICAL  SUBJECTS 

removed  by  operation  the  claim  that  the  mahgnant 
change  is  imposed  upon  a  simple  one  appears  on  patho- 
logical grounds  to  be  irrefutable;  and  every  surgeon 
knows  that  in  a  small  number — not  less,  certainly,  than 
10  per  cent. — of  the  cases  of  gastric  ulcer,  to  all  appear- 
ances simple  in  character,  a  microscopic  examination  of 
the  specimen  removed  by  operation  reveals  the  early 
stage  of  carcinoma.  Now,  histologists  do  not  always 
agree  as  to  the  conditions  which  may  be  accepted  as 
indicating  the  earUest  changes  from  simple  to  carcino- 
matous states.  Much  of  our  knowledge  of  the  micro- 
scopiceJ  appearances  of  cancer  is  based  upon  an  examina- 
tion of  specimens  long  dead,  of  specimens  months  or 
years  old,  which  have  been  lying  upon  the  laboratory 
or  museum  shelves.  The  changes  that  occur  in  such 
circumstances  are  not  known.  But,  as  I  have  ventured 
to  urge,  an  examination  of  specimens  so  recently  removed 
as  to  be  hardly  yet  dead  is  necessary  before  we  know 
what  conditions  in  carcinoma  are  authentic  and  what  are 
the  changes  which  are  merely  due  to  corruption.  We 
must  recognize  a  "histology  of  the  living,"  which  is 
probably  as  far  removed  from  the  histology  of  the  dead 
as  we  now  all  recognize  the  "pathology  of  the  living" 
to  be  from  the  pathology  of  the  dead. 

We  must  finally  consider  this  fact  also,  that  when 
gastro-enterostomy  is  performed  for  a  chronic  gastric 
ulcer,  the  "physiological"  results  of  the  operation,  though 
they  may  not  bring  about  the  healing  of  the  ulcer,  may 
yet  delay  or  prevent  its  progress  towards  carcinoma.  We 
must  take  account  of  the  possible  effects  produced  by  the 
change  from  an  acid  to  an  alkahne  medium.  Nothing  is 
more  remarkable  than  the  difference  in  destiny  of  a 
chronic  duodenal  ulcer  and  of  a  chronic  gastric  ulcer.     It 


CHRONIC  GASTRIC  ULCER  95 

is  admittedly  one  of  the  great  rarities  in  pathology  to  find 
an  ulcer  of  the  duodenum  that  has  become  mahgnant; 
and  it  is  certainly  a  far  more  frequent  thing,  allowing  for 
all  reservations,  to  find  an  ulcer  of  the  stomach  in  which 
carcinoma  has  developed.  Embryologically  the  stomach 
and  the  duodenum  as  far  down  as  the  ampulla  of  Vater  are 
one.  This  difference  in  the  prospective  changes  in  ulcers 
on  one  or  other  side  of  the  pylorus  may  be  due  to  the 
different  reactions  of  the  fluids  by  which  they  are  bathed. 
Those  who  practise  the  operation  of  gastro-enteros- 
tomy  for  the  relief  of  ulcers  in  the  body  of  the  stomach 
rely  upon  the  so-called  "physiological  results"  of  the  opera- 
tion— that  is,  upon  the  effect  produced  by  the  constant 
entry  into  the  stomach  through  the  anastomosis  of  the 
alkaline  bile  and  pancreatic  juice.  There  is  no  doubt  that 
these  juices  are  found  in  the  contents  of  the  stomach 
removed  by  tubage  in  all  cases  after  gastro-enterostomy 
has  been  performed;  and  it  is  possible  that  the  success  of 
the  best  methods  of  therapy  in  cases  of  gastric  ulcer — 
that  of  Sippy,  for  example  (in  which,  however,  gastric 
lavage  is  a  factor  of  great  value)^-depends  upon  the 
very  frequent  administration  of  alkahes,  which,  it  is 
claimed,  neutrahze  the  gastric  acidity,  and  so  allow  of 
healing  in  the  ulcer.  Much  of  the  explanations  given  is 
conjectural,  and  regard  is  perhaps  insufficiently  paid  to 
the  effect  of  the  administration  of  alkahes  in  provoking  a 
greater  output  of  acid  in  the  gastric  juice  to  overcome  the 
alkah  administered.  I  am  very  sceptical  as  to  any  sub- 
stantial "physiological"  value  possessed  by  the  opera- 
tion of  gastro-enterostomy.  Its  other  effects  are  purely 
mechanical.  The  stomach  is  emptied  more  quickly 
through  a  gastro-enterostomy  openiiig;  the  pyloric  spasm 
which  so  often  accompanies  gastric  ulceration  is  robbed 


96  ESSAYS  ON  SURGICAL  SUBJECTS 

of  its  effects,  and  the  persistent  local  spasm  which  causes 
the  characteristic  "incisura"  may  either  be  prevented 
by  a  division  of  the  muscular  fibres  causing  it  or  rendered 
ineffective  by  the  drainage  of  the  stomach  on  its  proximal 
side. 

The  making  of  an  anastomosis  between  the  stomach 
and  the  jejunum  does  not  prevent  the  subsequent  devel- 
opment of  a  gastric  ulcer.  I  have  records  of  one  case  in 
which  a  gastric  ulcer,  well  removed  from  the  anastomosis, 
developed  after  the  operation  and  went  on  to  perforation; 
and  of  three  others  in  which  gastric  ulceration  developed 
after  the  performance  of  gastro-enterostomy  for  a  duo- 
denal ulcer. 

Sherren^  records  a  case  of  carcinoma  of  the  stomach 
developing  in  a  patient  upon  whom  gastro-enterostomy 
was  performed  for  a  perforated  duodenal  ulcer.  Coffey, 
a  surgeon  of  great  sagacity,  in  a  paper  on  "Gastro- 
enterostomy Still  the  Operation  for  Chronic  Gastric  and 
Duodenal  Ulcer,"  records^  two  cases  in  which  an  ulcer  in 
the  stomach  developed  after  gastro-enterostomy  had  been 
performed  for  duodenal  ulcer. 

In  consequence  of  my  experience  I  have  abandoned 
gastro-enterostomy  alone  in  the  treatment  of  chronic 
gastric  ulcer,  for: 

(a)  The  results,  even  when  the  operation  was  "suc- 
cessful," were  not  so  satisfactory  as  those  which  now 
follow  gastrectomy.  The  morbidity  was  greater,  the  re- 
turn to  health  slower,  the  ability  to  take  food  early  and 
generously  was  wanting,  a  more  watchful  after-care  was 
necessary. 

(6)  Some  cases  returned  with  the  ulcer  still  open,  and  a 
further  operation  was  required.  In  such  cases  the  ulcer 
had  almost  always  perforated  all  the  waUs  of  the  stomach, 


CHRONIC  GASTRIC  ULCER  97 

and  adhesions  had  occurred  to  the  Hver,  pancreas,  or 
abdominal  wall. 

(c)  Some  few  cases  retm-ned  with  carcinoma  of  the 
stomach  after  so  long  an  interval  as  to  make  it  probable 
that  the  cancerous  change  had  occurred  after  the  operation 
had  been  performed.  Estimates  of  this  sort  are,  I  admit, 
fallacious,  for  the  chronicity  of  some  forms  of  mahgnant 
disease  of  the  stomach  is  remarkable.  I  have  recently 
been  consulted,  on  account  of  a  return  of  her  symptoms, 
by  a  patient  upon  whom  four  years  and  seven  months  ago 
I  performed  gastro-enterostomy  for  carcinoma  of  the  lesser 
curvature  of  the  stomach,  causing  obstruction,  when 
secondary  deposits  were  present  in  many  glands,  in  the 
falciform  hgament  (one  of  these  nodules  was  removed  for 
microscopical  examination  and  confirmed  the  diagnosis), 
and  the  hver. 

(d)  There  is  evidence  to  show  that  gastric  ulcer  may 
develop,  even  after  gastro-enterostomy  has  been  per- 
formed, when  the  stomach  itself  was  normal. 

The  operation  of  gastro-enterostomy  is  made  as  simple 
as  possible,  though  it  is  by  no  means  always  easy.  Clamps 
are  used,  and  vertical  appHcation  of  the  highest  ac- 
cessible portion  of  the  jejunum  is  made  to  the  posterior 
surface  of  the  stomach  along  a  fine  which  is  a  continua- 
tion downwards  of  the  upper  part  of  the  lesser  curvature. 
In  this  way  the  lowest  portion  of  the  stomach  is  drained 
by  the  new  opening.  Two  layers  of  sutures  are  used ;  both 
are  of  the  finest  chromic  catgut  (six  nought).  It  is  never 
necessary  to  have  more  than  two  layers,  nor  to  use  any 
unabsorbable  material,  such  as  hnen  or  thread  or  coarse 
chromic  catgut.  Any  large  vessel  springing  from  the 
greater  curvature  and  running  directly  on  to  the  anasto- 
motic fine  is  hgatured  separately.     The  opening  into  the 


98  ESSAYS  ON  SURGICAL  SUBJECTS 

lesser  sac  is  carefully  closed  by  approximating  the  cut 
edges  of  the  transverse  mesocolon  to  the  suture  line.  The 
principles  appUcable  in  all  operations  are  observed — gentle 
handling,  absence  of  exposure  or  chiUing  of  any  parts 
directly  engaged  in  the  operation,  and  scrupulous  care  at 
every  step.  The  mortahty  in  my  own  hands  during  the 
last  ten  years  is  1  per  cent.,  and  there  has  been  no  death 
in  the  last  350  cases  of  gastric  or  duodenal  ulcer. 

II.  Excision 

The  operation  of  excision  was  introduced  with  great 
hopes,  which,  unhappily,  have  not  been  gratified.  I  have 
practised  excision  by  several  routes,  and  have  removed 
ulcers  of  various  sizes.  A  small  ulcer  on  the  anterior  or 
posterior  surface  has  been  excised,  and  the  opening  left  in 
the  stomach  either  closed  by  interrupted  sutiu-es  of  catgut 
or  utilized  to  form  an  anastomosis  with  the  jejunum. 
Wedge-shaped  excision  of  ulcers  on  the  lesser  curvature 
has  been  carried  out,  sometimes  with  ease,  oftener  with 
difficulty,  and  with  a  resulting  deformity  of  the  stomach. 
Ulcers  on  the  posterior  wall,  perhaps  burrowing  into  the 
pancreas,  have  also  been  removed  through  an  incision  in 
the  anterior  wall  of  the  stomach.  I  have  been  profoundly 
disappointed  with  the  results.  My  colleague,  Mr.  Collin- 
son,  in  a  paper  read  before  the  American  Medical  Asso- 
ciation in  1914,^  found  that  in  thirty-nine  cases  of  excision 
there  were  fifteen  in  which  severe  recurrence  of  symptoms 
was  observed.  Eleven  patients  were  submitted  to  a 
second  operation,  and  seven  of  them  showed  active 
ulceration  at  the  site  of  the  excision,  one  had  developed 
a  fresh  ulcer  distal  to  the  original  one,  and  three  had 
extensive  adhesions  which  crippled  the  action  of  the 
stomach.    The  operation  may  fail  on  account  of  technical 


CHRONIC  GASTRIC  ULCER  99 

errors.  Too  small  an  area  of  induration  surrounding  the 
actual  crater  may  be  removed;  the  hard,  stiffened  edges 
of  the  wound  which  remain,  infiltrated  by  inflammatory 
products  which  have  long  been  there,  may  not  heal 
kindly  or  rapidly,  and  fresh  ulceration  may  start  be- 
fore cicatrization  is  complete.  Of  such  a  condition  I 
found  evidence  in  a  case  of  my  own,  related  by  Mr. 
CoUinson  in  the  paper  to  which  I  have  referred.  In 
other  cases  a  deformity  of  the  stomach  may  be  consequent 
upon  the  removal  of  an  ulcer,  especially  of  one  which  lay 
upon,  or  near,  the  lesser  curvature;  the  normal  peristaltic 
movements  wiU  then  be  checked  at  the  fine  of  scar,  as  a 
radiological  examination  will  plainly  declare.  The  use  of 
unabsorbable  sutm*es,  especially  continuous  sutures,  may 
lead  to  secondary  ulceration.  All  continuous  "sero- 
muscular" sutures  probably  penetrate  to  the  mucosa  in 
more  places  than  one;  if  this  occurs,  the  sutm'e  wiU  even- 
tuaUy  ulcerate  its  way  through  to  the  lumen  of  the  bowel 
and  be  discharged,  or  hang  loose  at  the  suture  line  for 
months  or  years.  Finally,  even  with  a  careful  technique, 
adhesions  may  form  between  the  suture  line  and  any 
viscus  or  the  abdominal  wall  in  contact  with  it,  and  some 
embarrassment  of  the  action  of  the  stomach  will  then 
certainly  result. 

For  these  reasons,  and  in  spite  of  some  very  satisfactory 
results,  I  have  abandoned  the  operation  altogether  in 
cases  of  gastric  ulcer.  The  disappointments  it  brings  are 
too  many,  and  are  neither  easy  to  foresee  nor  certednly  to 
be  prevented. 


iOO  ESSAYS  ON  SURGICAL  SUBJECTS 

III.  Excision,  by  Knife  or  by  Cautery,  Combined  with 
Gastro-enterostomy 

At  an  early  stage  in  our  experience  of  the  operation  of 
excision  alone  it  was  found  that  in  some  instances,  after 
suture  of  the  wound  was  complete,  a  considerable  degree 
of  distortion  of  the  stomach  resulted,  the  lesser  curvature 
was  much  puckered,  and  the  whole  organ  warped  in  out- 
line. To  have  left  the  stomach  in  such  a  condition  would 
inevitably  have  meant  that  a  further  operation  would  soon 
be  necessary  in  order  to  overcome  mechanical  difficulties. 
And  little  by  little  it  became  the  practice  to  combine  with 
the  operation  of  excision  that  of  gastro-enterostomy  also. 
The  results  were  certainly  better  than  before,  but  the 
combined  operations,  in  point  of  difficulty  always,  and 
often  in  point  of  time  and  of  danger  also,  equalled  or  ex- 
ceeded the  operation  of  partial  gastrectomy.  As  the 
technique  of  this  latter  operation  was  steadily  improved,  it 
began  in  my  own  hsinds  to  replace  other  methods,  and  I 
reverted  to  the  practice  so  ably  advocated  by  Rodman, 
of  "removal  of  the  ulcer-bearing  area." 

Balfour  of  Rochester,  with  that  fertihty  of  resource 
which  is  one  of  the  characteristics  of  his  fine  work,  re- 
placed the  method  of  excision  of  the  ulcer  by  that  of  its 
complete  destruction  by  the  actual  cautery.  Balfour's 
operation  has  among  its  many  merits  that  of  simphcity. 
If  an  ulcer  lie  upon  the  lesser  curvature,  or  near  it,  a 
little  nearer  the  cardia  than  the  pylorus,  or  down  upon  the 
posterior  wall,  the  operation  of  excision  was  apt  to  be 
difficult.  The  method  of  Balfour  makes  the  treatment 
very  much  easier,  quicker,  safer,  and  gives  results  far 
more  satisfactory.  I  learnt  the  method  in  Rochester, 
where  I  saw  several  operations  performed  by  W.  J.  Mayo. 


CHRONIC  GASTRIC  ULCER  101 

In  ulcers  near  or  upon  the  lesser  curvature  there  is  often 
a  covering  of  fat,  developed  probably,  as  in  the  case  of  an 
infected  gall-bladder,  as  a  protection  against  perforation. 
This  fat  is  dissected  upwards  towards  the  lesser  curvature, 
until  the  base  of  the  ulcer  is  seen  clearly.  The  crater  of 
the  ulcer  is  then  completely  destroyed  by  the  actual 
cautery,  which  pierces  the  entire  thickness  of  the  wall  of 
the  stomach.  The  gap  which  remains  is  closed  by  in- 
terrupted sutures,  in  two  layers,  and  the  flap  of  fat  turned 
downwards  to  cover  the  suture  line  like  a  Ud.  Posterior 
gastro-enterostomy  is  then  performed  in  the  usual  manner. 

Of  all  methods  of  dealing  with  gastric  ulcer,  short  of 
gastrectomy,  I  am  convinced  that  this  is  one  of  the  best; 
it  destroys  the  ulcer  more  completely  than  does  the  method 
of  excision,  for  the  effect  of  the  cautery  extends  widely 
beyond  the  seared  edge  of  the  woimd.  If  by  chance  there 
is  an  early  carcinomatous  change,  it  is  probable  that  much 
of  the  risk  of  local  recurrence  is  removed.  No  more  tissue 
is  sacrificed  than  is  necessary,  and  the  sutiu'e  of  the  woimd 
offers,  as  a  rule,  no  difficulty. 

My  own  experience  of  this  operation  is  smaU.  At  the 
time  when  I  should  have  been  inclined  to  make  it  an 
almost  routine  procedure  for  many  cases  I  had  been  led  by 
my  unsatisfying  experience  of  other  methods  to  become 
more  and  more  radical  in  the  treatment  of  gastric  ulcer, 
and  to  consider  the  removal  of  the  part  of  the  stomach  as 
the  operation  of  choice.  There  are,  however,  cases  in 
which  everyone  wiU  admit  the  great  value  of  the  operation : 
cases  of  ulcers  difficult  of  access,  in  patients  for  whom, 
because  of  recent  haemorrhages,  or  a  degree  of  pain  which 
has  made  the  taking  of  food  exceedingly  difficult,  the 
simplest  operation  that  is  sufficient  to  cure,  or  relieve  the 
disease,  is  indicated. 


i02  ESSAYS  ON  SURGICAL  SUBJECTS 

IV.  Gastro-enterostomy  Combeved  with  Jejunostomy 

This  is  a  method  which  I  have  advocated  and  practised 
in  cases  of  grave  difficulty.  The  results  have  been  ex- 
cellent. There  are  ulcers  of  the  stomach  so  large,  so 
awkwardly  placed,  and  so  deeply  penetrating  the  liver, 
or  the  pancreas,  in  patients  whose  general  condition  is  so 
poor  that  any  operation  becomes  serious.  Such  cases  may 
be  unsuitable  for  Balfour's  operation,  by  reason  of  the  size 
or  remoteness  of  the  ulcer;  and  for  the  operation  of 
gastrectomy  by  reason  of  the  extremely  feeble  condition 
of  the  patient,  who  has  perhaps  recently  suffered  from  a 
copious  haemorrhage.  In  aU  such  cases  I  perform  gastro- 
enterostomy in  "Y,"  generally  by  the  anterior  route.  The 
intestine  is  cut  across  about  18  in.  below  the  flexure,  the 
distal  end  closed,  and  the  side  of  this  distal  part  united 
to  the  anterior  wall  of  the  stomach.  As  large  an  opening 
as  possible  is  made  proximal  to,  or  in  the  zone  of,  the  ulcer 
and  extending  sometimes  over  the  fundus  of  the  stomach. 
The  proximal  divided  end  of  the  jejunum  is  then  anas- 
tomosed to  the  side  of  the  distal  limb  a  few  inches  below 
the  gastro-enterostomy  opening.  Into  this  proximal  part, 
at  a  point  about  3  in.  above  the  junction  which  has  just 
been  made  with  the  disteJ  limb,  a  tube  is  introduced  and 
fixed  by  the  method  of  Witzel.  The  tube  passes  for 
several  inches  down  through  the  entero-anastomosis 
into  the  jejunum.  It  is  brought  out  of  the  gJ^dominal 
wall  through  a  small  separate  incision  to  the  left  of 
the  umbilicus.  It  is  through  this  tube  that  all  nourish- 
ment is  given  for  months,  or  for  years,  until  a  radiological 
examination  shows  that  the  ulcer  is  healed,  or  until  a 
trial  of  one  month,  during  which  food  is  given,  discloses 
no  return   of  the   symptoms.    During   this   time   the 


CHRONIC  GASTRIC  ULCER  103 

greatest  care  is  taken  to  keep  the  mouth  clean  by  friction 
and  frequent  washing.  I  have  never  had  any  difficulty 
with  a  patient  craving  for  food.  The  sufferings  endured 
before  operation,  and  the  rehef  immediately  afterwards, 
by  their  sharp  contrast,  make  the  patient  disposed  to  do 
all  one  asks.  One  patient,  whose  stomach  showed  the 
largest  ulcer  I  have  ever  seen  (we  described  it  as  resembhng 
the  mouth  of  a  letter  box  through  which  the  hand  passed 
deeply  into  the  Hver),  took  no  food  for  two  years  and  nine 
months  after  this  operation,  though  I  gave  her  permission 
to  do  so.  She  took  food  generously  through  the  tube, 
and  gained  over  50  pounds  in  weight.  Since  removing 
the  tube,  now  a  few  years  ago,  there  has  been  no  recur- 
rence of  symptoms.  Indeed,  up  to  the  present  time,  in 
no  case  in  which  this  operation  has  been  practised  has 
the  ulcer  returned. 

V.  Resection  of  a  Part  of  the  Body  of  the  Stomach 
— "Sleeve  Resection" 

This  operation  is,  of  course,  reserved  for  those  cases  in 
which  the  ulcer  occupies  approximately  the  middle  part  of 
the  stomach.  After  resection  of  a  cyHndrical  portion  of 
the  organ  the  cut  ends  are  united.  Advocacy  of  this 
operation  appears  to  be  restricted  to  a  few  surgeons,  and 
consequently  the  number  of  cases  performed  is  relatively 
small.  I  practised  it  on  two  occasions  only,  long  ago.  In 
both  the  operation  promised  well,  but  one  of  the  patients 
returned  after  four  years  with  an  hour-glass  stomach,  for 
which  a  second  operation  was  necessary.  The  role  of  the 
operation  is  necessarily  a  very  limited  one.  I  think  I  am 
hardly  likely  to  perform  it  again.  But  so  far  as  I  can 
judge  of  the  experience  of  others  it  has  had  a  fair  measure 
of  success. 


iO^  ESSAYS  ON  SURGICAL  SUBJECTS 

VI.  Partial  Gastrectomy 

My  early  experience  of  the  operations  already  men- 
tioned was  satisfactory  enough  so  far  as  immediate  results 
were  concerned;  but  as  time  passed  patients  began  to  re- 
turn with  one  degree  of  discomfort  or  another,  until  I  was 
convinced  that  many  of  the  methods  practised  were  not 
justified  by  their  end-results.  And  by  degrees  I  was 
brought  to  realize  that  gastric  ulcer  was  a  far  more  serious 
disease  than  duodenal  ulcer.  It  was  soon  found  to  be 
comparatively  a  rare  disease,  far  less  frequent  in  occur- 
rence than  had  been  universally  beheved,  and  certainly 
very  difficult  indeed  to  diagnose  with  confident  assurance 
and  constant  accuracy.  The  diagnosis  so  frequently  made 
of  "gastric  ulcer"  in  out-patient  rooms  and  in  private 
practice  is  not  sustained  when  the  parts  are  examined 
upon  the  operation  table.  Other  diseases — duodenal 
ulcer,  chronic  appendicitis,  choleHthiasis,  tuberculous 
enteritis,  laxity  of  the  attachments  of  the  colon — are  all 
found  in  the  absence  of  any  palpable  or  visible  lesion  of 
the  stomach,  and  explain  the  symptoms  of  which  the 
patient  has  complained.  A  host  of  diseases,  organic  and 
functional  alike,  are  called  "gastric  ulcer."  And  conse- 
quently much  of  the  literature  and  most  of  the  statistics 
dealing  with  the  subject  of  "gastric  ulcer"  lack  that 
foundation  of  truth  which  only  an  accurate  diagnosis  can 
afford. 

In  the  cases  of  indisputable  gastric  ulcer,  when  the 
ulcer  is  demonstrated  beyond  cavil  by  a  radiological 
examination  or  by  inspection  upon  the  operation  table, 
a  far  greater  seriousness  attaches  to  the  disease  than  to 
the  condition  of  duodenal  ulcer.  Operations  upon  it  are 
more  serious,  partly  by  reason  of  the  extent  of  the  opera- 


CHRONIC  GASTRIC  ULCER  105 

tions  themselves,  chiefly,  I  think,  in  consequence  of  the 
less  robust  state  of  the  patients.  Recoveries  after 
operation  are  fewer  whatever  the  nature  of  the  opera- 
tion, and  the  rate  of  mortaUty  of  the  patients  in  the  years 
subsequent  to  operation,  as  Balfour  has  recently  shown 
in  a  paper  of  great  value  and  of  new  significance,*  is, 
in  the  cases  attended  in  the  Mayo  CHnic,  three  times  as 
high  as  in  patients  operated  upon  for  duodenal  ulcer. 
This,  on  reflection,  is  not  so  startHng  a  fact  as  may  at 
first  appear;  for  many  of  the  patients  suffering  from 
duodenal  ulcer  are  men  otherwise  of  robust  strength  and 
splendid  health.  I  have  operated  upon  international 
football  players,  golfers,  lacrosse  players,  and  many  dis- 
tinguished athletes  for  duodenal  ulcer.  Such  people  are 
not  often  found  among  those  who  suffer  from  gastric 
ulcer;  and,  though  there  are  exceptions,  the  types  of 
stomach  found  in  the  two  diseases  are  distinct  from  one 
another,  as  Hurst  has  shown.  The  local  conditions  found 
in  the  two  diseases  are  different  also.  A  duodenal  ulcer 
is  often  a  simple  round  "terraced"  ulcer  affecting  the 
intestine  alone;  a  gastric  ulcer  is  very  prone  to  extend 
and  to  burrow  deeply  into  other  parts — the  pancreas,  the 
liver,  the  abdominal  wall;  and  the  later  history  of  the  two 
diseases  is  very  different.  I  lean  to  the  belief  that  many 
of  the  cases  of  carcinoma  of  the  stomach  with  which 
the  surgeon  can  deal  successfully  have  their  origin  in  a 
chronic  ulcer.  That  is  not  the  universal  view,  but  the 
opinion  of  those  who  hold  it  is  weighty  and  well  founded. 
Carcinoma  is  excessively  rare  in  that  part  of  the  duo- 
denum affected  by  chronic  ulcer.  Prompted  by  edl  these 
considerations,  I  was  graduaUy  brought  to  view  gastric 
ulcer  as  a  disease  requiring  direct  and  radical  treatment, 
and  that  it  was  not  safe  to  trust  to  the  indirect  method 


i06  ESSAYS  ON  SURGICAL  SUBJECTS 

of  gastro-enterostomy,  which,  whether  its  action  is 
"physiological"  or  mechanical,  merely  produces  a  con- 
dition of  things  in  which  heahng  can  more  easily  take 
place. 

My  choice  of  operation  now  always  falls  upon  partial 
gastrectomy,  whenever  it  can  with  reasonable  safety  be 
performed.  The  risk  is  not  great:  over  a  period  of  ten 
years  it  is  not  more  than  2.5  per  cent.  All  things  con- 
sidered, and  account  being  taken  of  the  five  years  suc- 
ceeding operation,  it  is  probably  a  safer  operation  and 
is  certainly  more  immediately  satisfactory  than  gastro- 
enterostomy alone.  It  cannot  always  be  practised.  The 
condition  of  the  patient  may  forbid  it.  The  ulcer  may  be 
so  large  and  so  placed  as  to  make  removal  a  matter  of  so 
great  technical  difficulty  that  the  inunediate  hazards  are 
unfair  to  the  patient.  But  as  experience  grows  the 
number  of  such  cases  diminishes.  Nowadays  I  rarely 
practise  any  other  operation  than  partial  gastrectomy  or 
gastro-enterostomy  in  "Y"  combined  with  jejunostomy. 
The  details  of  the  operation  of  gastrectomy  are  briefly 
these:  The  duodenum  is  divided  just  beyond  the  pylorus, 
after  ligature  of  the  pyloric  and  gastro-duodenal  arteries. 
An  opening  is  made  in  the  transverse  mesocolon,  in  the 
arch  of  the  anastomosis  of  Riolan  in  order  to  guide  the 
surgeon  in  his  ligature  of  the  omentum  below  the  greater 
curvature,  so  that  the  middle  cohc  artery  may  be  avoided, 
and  in  order  that  the  conditions  at  the  back  of  the  stomach 
may  be  early  and  fully  investigated.  After  division  of 
the  great  omentum  as  far  towards  the  left  as  the  point 
at  which  the  stomach  is  to  be  divided,  the  whole  organ  is 
turned  over  the  left  edge  of  the  parietal  wound,  until  the 
coronary  artery  is  brought  into  view  and  Ugatured  with 
great  ease  at  exactly  the  place  required.    As  soon  as  this 


CHRONIC  GASTRIC  ULCER  i07 

vessel  is  cut  an  anchor  is  "let  go,"  and  the  stomach  is 
moved  more  freely.  Then  while  the  stomach  is  held  as  a 
retractor  an  anastomosis  is  made  between  it  and  the 
jejunum.  I  now  always  apply  the  end  of  the  stomach  to 
the  side  of  the  jejuniun. 

In  my  early  cases  I  twice  encountered  a  Httle  diffi- 
culty in  making  the  jejunum  so  apply  itself  to  the  stomach 
as  to  avoid  a  kink  at  the  upper  end  of  the  anastomosis. 
In  both  cases  some  biUous  vomiting  occurred.  In  order 
to  prevent  this  I  now  usually  divide  the  jejunum  com- 
pletely across,  about  eight  to  ten  inches  below  the  duo- 
deno-jejunal  flexure,  close  the  distal  end,  and  make  an 
anastomosis  in  "Y."  This  takes  a  few  minutes  longer, 
but  the  expenditure  of  time  is  worth  while.  The  results 
are  excellent.  The  condition  after  operation  is  remark- 
ably good;  in  almost  all  cases  the  patients  have  the  most 
tranquil  progress  that  one  could  wish.  And  not  one  sin- 
gle case  I  have  ever  operated  upon  has  had  a  recurrence 
of  trouble.  Once  the  convalescence  is  complete  the  his- 
tory is  without  incident. 

Whatever  the  operation  from  among  all  those  men- 
tioned which  may  be  selected  in  each  individual  case 
regard  must  always  be  paid  to  the  power  of  the  patient  to 
bear  it,  and  to  its  exact  appHcation  to  the  particular 
conditions  disclosed  when  the  parts  are  directly  examined. 
Before  the  operation  commences  the  surgeon  should  never 
reach  a  definite  decision  to  perform  any  one  procedure;  he 
must  apply  at  the  moment  of  operation  the  method  which 
best  meets  the  indications  in  each  case.  And  here,  as 
elsewhere,  the  httle  things  count.  Care  in  preparation, 
scrupulous  exactitude  in  every  detail,  gentleness,  dehbera- 
tion,  with  such  speed  as  comes  naturally  from  much 
practice,  and  is  unsought  as  a  special  feature — all  these 


i08 


ESSAYS  ON  SURGICAL  SUBJECTS 


together  will  sometimes  turn  what  would  otherwise  be 
failm-e  into  easy  and  certain  success. 

Statistics 

For  the  purpose  of  illustrating  my  practice  in  con- 
nexion with  operations  upon  the  stomach  and  duodenum  I 
have  collected  together,  with  the  help  of  my  colleague,  Mr. 
E.  R.  Flint,  and  my  secretary,  Miss  Mackill,  all  the  records 
of  cases  operated  upon  by  myself  since  the  year  1909,  in- 
cluding the  very  lean  years  of  war.  Every  case  of  simple 
disease  of  the  stomach  or  duodenum  (excepting  acute  per- 
foration) is  included:  cases  of  gastric  ulcer,  hom*-glass 
stomach,  duodenal  ulcer,  and  jejunal  or  gastro-jejunal 
ulcer  following  upon  gastro-enterostomy. 

The  cases  of  ulceration*  are  as  follows: 

Ulceration 


Grastric  ulcer  alone 

Gastric  ulcer  with  duodenal  ulcer  (including  some  cases 

of  hour-glass  stomach) 

Gastric  ulcer  alone  causing  hour-glass  stomach 

Duodenal  ulcer  alone 

Pyloric  ulcer 

Jejunal  or  gastro-jejunal  ulcer 


Cases. 


Deaths. 


196) 

37  H 

7  =  2.7% 

23 
605 
9 
33 

3  =  0.49% 
0 

2  =  6.0% 

The  greater  severity  of  cases  of  gastric  ulcer  as  com- 
pared with  duodenal  ulcer  is  strikingly  shown;  and  the 
serious  nature  of  cases  of  jejunal  ulcer  is  evident. 


*  The  figures  in  these  tables  have  been  brought  up  to  December,  1920. 


CHRONIC  GASTRIC  ULCER 


109 


Operations  Performed 


Operation. 


GMtxectomy . 


Gastxo-enterostomy — 

Posterior 

Anterior 

In"Y" 

In  "Y"  with  jejnnostomy 

With  gastrostomy 

(All  these  combined  in  a 
great  majority  of  cases 
with  removal  of  the  ajj- 
pendix,  and  several  with 
operations  upon  the  gall- 
bladder. In  two  ovariot- 
omy was  performed  also.) 

Ebccision  of  gastric  or  duo- 
den£d  ulcer  with  or  with- 
out gastro-enterostomy, 
including  Balfour's  opera- 
tion. 

Hour-glass  stomach  (mul- 
tiple operations,  gastro- 
enterostomy with  gastro- 
gastrostomy,  etc.). 


Jejunostomy . 


Caises. 


100 


}      738 


19 


Deaths. 


2  =  2.0% 


■!=\% 


One  case  of  almost  total 
gastrectomy  for  large  mul- 
tiple ulcers,  eroding  the 
pancreas  and  the  Uver. 

Five  deaths  were  due  to  lung 
compUcations,  associated 
in  one  with  tuberculosis. 


Remeu'ks. 


The  fatal  case  was  one  of 
duodenal  ulcer;  cholecys- 
tectomy and  appendicec- 
tomy  were  also  performed. 


Post-mortem  report:  "Ex- 
treme fatty  infiltration  of 
right  auricle  and  ventricle, 
cbronic  fibrosis  of  kid- 
neys." 

The  fatal  case  had  a  gastro- 
jejunal  ulcer  of  l8U"ge  size, 
with  much  induration 
around  it.  The  patient 
was  exceedingly  ill,  and 
suffering  intense  pain. 


Summaiy 
There  were  in  all  905  operations,  with  12  deaths — a 
total  mortality  of  1.32  per  cent.  Excluding  the  cases 
of  jejunal  ulcer  there  were  872  operations  on  cases  of  gas- 
tric and  duodenal  ulcers,  with  10  deaths — a  mortahty  of 
1.14  per  cent. 

References. 
1  Lancet,  1920,  i,  p.  698.    *  Annals  of  Surgery,  1920,  i,  p.  303.    *  Jown.  Amer. 
Med.  Assoc.,  1914,  Ixiii,  p.  1184.    *  Annals  of  Surgery,  1919,  Lex,  p.  522. 


DISAPPOINTMENTS  AFTER  GASTRO- 
ENTEROSTOMY 

Every  operation  in  surgery,  even  the  best,  most  ex- 
quisitely performed,  may  bring  its  disappointments.  The 
operation  of  gastro-enterostomy,  carried  out  in  appro- 
priate cases  by  a  competent  operator,  is  probably  the 
most  successful  of  all  surgical  procedures  of  equal  magni- 
tude, and  it  is  certainly  among  the  safest  of  those  entitled 
to  the  description  of  major  operations.  In  my  last  series 
of  more  than  300  non-mahgnant  cases  I  have  not  lost  a 
patient,  and  in  recent  years  a  temporarily  unsatisfactory 
result  has  been  extremely  rare. 

When  we  speak  of  disappointments  after  gastro-enter- 
ostomy, we  must  first  remember  that  it  may  not  be  the 
fault  of  the  operation  but  of  many  other  circumstances  if 
things  go  wrong.  The  success  or  failure  of  an  operation 
may  be  due  not  only  to  the  procedure  itself  but  also  to 
its  performance  in  cases  which  did  not  need  it. 

It  falls  to  my  lot  to  see  many  cases  in  which  the  opera- 
tion of  gastro-enterostomy  has  failed,  and  in  reviewing 
these  I  find  that  they  are  capable  of  tabulation  in  the 
following  manner: 

A.  THE  OPERATION  HAS  BEEN  PERFORMED  IN  THE 
ABSENCE  OF  ANY  ORGANIC  LESION  JUSTIFYING  IT 

This  is  by  far  the  most  frequent  cause.  In  every 
ten  cases  of  unsatisfactory  results  nine  are  due  to  this 
cause  and  to  this  alone. 

Reprinted  from  the  British  Medical  Journal,  July  12,  1919. 
Hi 


ii2  ESSAYS  ON  SURGICAL  SUBJECTS 

The  conditions  for  which  the  operation  has  been  need- 
lessly performed  are  two: 

(a)  In  Functional  Disorders  of  the  Stomach 

The  more  we  know  of  organic  diseases  of  the  stomach 
the  fewer  do  those  cases  formerly  considered  fmictional 
progressively  become.  It  is  not  so  long  since  a  patient 
suffering  from  duodenal  ulcer,  for  example,  was  fre- 
quently told  that  he  was  the  victim  of  "acid  gastritis," 
or  "acid  dyspepsia,"  "hyperchlorhydria,"  or  "neuralgia  of 
the  stomach,"  all  of  which  were  said  to  be  functional 
states. 

When  I  first  called  attention  to  the  symptoms  and  to 
the  clinical  diagnosis  of  duodenal  ulcer,  I  found  it  difficult 
to  persuade  many  of  my  friends  that  I  was  speaking  of 
a  common  organic  lesion  which  could  be  demonstrated 
during  an  operation  to  any  inteUigent  onlooker. 

To-day  every  one  agrees  that  these  symptoms  are  in 
truth  due  to  a  structural  lesion  and  not  to  a  vice  in  the 
chemistry  or  a  defect  in  the  motility  of  the  stomach. 
And  this  holds  good  of  other  "functional  diseases"  of  the 
stomach  also.  Inquiry  upon  the  operation  table  reveals 
organic  causes. 

There  still  remain,  however,  a  number  of  difficult  cases 
of  functional  troubles  associated  with  atony  of  the  stomach 
or  prolapse  of  this  and  other  abdominal  organs.  Such 
cases  may  be  difficult  to  treat  by  medical  means,  massage, 
exercises,  and  so  forth;  but  they  are  often  made  very  much 
worse  by  the  performance  of  a  short-circuiting  operation. 
If  such  patients  vomited  before,  they  vomit  still,  though 
the  character  of  the  vomit  is  altered  by  the  addition  of 
large  quantities  of  bile.  In  a  few  instances  the  patients 
wiU  say  that  they  are  neither  better  nor  worse,  and  I  have 


GASTRO-ENTEROSTOMY  ii3 

known  one  or  two  who  incline  to  think  their  condition  a 
little  better  than  it  was  before  operation.  But  the  excep- 
tions are  very  few  to  the  rule  that  in  these  conditions 
surgical  measures  are  harmful  or  disastrous. 

In  such  patients  the  only  further  operative  treatment 
which  the  surgeon  should  undertake  is  the  reparation  of 
the  mistakes  of  his  too  enterprising  predecessor.  The 
anastomosis  must  be  undone,  and  the  stomach  and  intes- 
tine returned  as  far  as  possible  to  their  original  condition. 
If  there  is  a  moderate  degree  of  visceral  prolapse  great 
reUef  may  be  obtained  from  the  appHcation  of  a  Curtis 
belt  or  of  corsets. 

(6)  In  Cases  of  Chronic  Disease  Elsewhere 

For  several  years  I  have  endeavoured  on  many  occa- 
sions to  emphasize  the  importemce  of  verifying,  after  the 
abdomen  is  opened,  the  original  diagnosis  of  ulcer  of  the 
stomach  or  of  the  duodenum,  before  beginning  any  opera- 
tion designed  to  relieve  the  patient  of  his  symptoms.  An 
ulcer  of  the  duodenum  or  of  the  stomach,  if  the  cause  of 
symptoms  so  long  continued,  or  so  severe  as  to  justify  an 
operation,  is  always  a  visible,  demonstrable,  palpable 
lesion.  If  no  ulcer  is  found  no  operation  should  be  per- 
formed. The  day  is  long  past  when  a  surgeon  is  entitled 
to  accept  a  chnical  diagnosis,  however  confidently  made, 
as  a  sufficient  warrant  for  an  operation.  The  lesion  sup- 
posed to  exist  must  be  recognized  at  the  time  the  abdomen 
is  opened  before  any  further  steps  are  taken  with  the 
intended  operation.  This  rule,  which  should  appeal  to 
every  one,  is  still  violated  with  no  httle  frequency.  If  no 
ulcer  is  found,  a  search  should  then  be  made  elsewhere  in 
the  abdomen  for  a  possible  cause  of  those  symptoms  which 
have  been  attributed  to  a  chronic  ulcer.     Failure  to  ob- 


lU  ESSAYS  ON  SURGICAL  SUBJECTS 

serve  these  precautions,  and  to  remember  this  unalterable 
rule,  has  resulted  in  the  performance  of  gastro-enteros- 
tomy  for  conditions  remote  from  the  stomach.  The 
operation  of  gastro-enterostomy  has  been  performed  for 
the  following  diseases: 

I.  Chronic  Appendicitis 

This  is  the  commonest  of  the  mistakes  in  this  class. 
Many  physicians  and  surgeons  have  long  realized  how 
exact  the  mimicry  of  the  symptoms  of  ulcer  of  the  stomach 
or  of  the  duodenum  may  be  in  cases  of  chronic  appen- 
dicitis. Nine  years  ago^  "appendix  dyspepsia,"  a  condi- 
tion in  which  symptoms  closely  resembling  those  due  to 
gastric  ulceration  were  caused  by  a  chronic  lesion  in  the 
appendix,  was  described,  and  special  attention  was  called 
to  the  presence  of  haematemesis  or  melaena  in  these  cases. 
Haematemesis  is  more  common  in  other  diseases  than  in 
gastric  ulcer,  of  which  it  is  not  a  very  frequent  symptom. 
The  occurrence  of  haemorrhage  should  therefore  raise  at 
once  a  suspicion  not  only  of  ulcer,  but  of  chronic  appen- 
dicitis, splenic  anaemia,  or  cirrhosis  of  the  liver. 

II.  Tuberculous  Disease  of  the  Intestine 

Tuberculous  disease  of  the  ileum,  or  caecum  and 
ascending  colon  has  been  present  in  a  small  number  of 
cases  where  gastro-enterostomy  had  been  performed  in 
the  absence  of  any  ulcer  of  the  stomach  or  duodenum. 

Tuberculous  disease  of  the  intestine  appears  to  be  a 
common  disorder  in  England  and  in  Scotland.  The  im- 
purity of  the  milk  supply,  of  course,  is  responsible  for  this. 
Manchester  has  recently  discovered  that  35  per  cent,  of  the 
milk  brought  to  it  contains  living  tubercle  baciUi,  and 


GASTRO-ENTEROSTOMY  U5 

a  similar  alarming  discovery  could  doubtless  be  made  in 
other  towns  if  inquiry  were  instituted.  The  symptoms 
produced  are,  as  a  rule,  clear  evidence  of  tuberculous 
disease;  but  occasionally  a  patient  may  present  such 
symptoms  as  make  a  diagnosis  of  duodenal  ulcer  not 
impossible.  There  are  pyloric  spasm,  hyperacidity,  pain, 
and  vomiting.  I  have  found  tuberculous  disease  of  this 
kind  in  two  medical  men  who  beKeved  themselves  to  be 
the  subject  of  duodenal  ulcer,  and  whose  belief  was 
strengthened  by  other  opinions.  Both  were  a  Httle  dis- 
mayed when  they  learnt  that  gastro-enterostomy  had  not 
been  performed;  but  both,  I  am  glad  to  say,  are  cured 
by  their  operations.  I  have  had  one  patient  sent  to  me 
as  a  case  of  "gastric  ulcer"  upon  whom  I  performed 
colectomy  for  hyperplastic  tuberculous  disease  of  the 
caecum. 

III.  Cholelithiasis,  or  Carcinoma  of  the 
Gall-bladder 

Cholehthiasis,  in  all  cases  except  those  in  which  a  single 
cholesterin  stone  is  present,  declares  its  presence,  even  in 
early  stages,  by  the  symptoms  of  dyspepsia,  and  often  also 
of  hyperacidity.  The  pain  of  flatulence  and  of  heaviness 
comes  with  fair  regularity  about  half  an  hour  after  a  meal. 
There  may  be  vomiting,  and  there  is  often  much  complaint 
of  acidity.  A  very  large  proportion  of  the  cases  of  chole- 
hthiasis, at  a  time  when  no  cohc  has  occurred,  are  diag- 
nosed as  cases  of  gastric  disease. 

The  way  to  prevent  this,  and  so  many  other  mistakes, 
is  to  examine  all  parts  of  the  abdomen  likely  to  be  affected 
by  disease,  before  the  purposeful  part  of  the  operation  is 
begun. 


il6  ESSAYS  ON  SURGICAL  SUBJECTS 

TV.  Cirrhosis  of  the  Liver,  with  Haemorrhage 

In  cirrhosis  of  the  liver  there  is  often  dyspepsia;  flatu- 
lence, heaviness,  soreness,  frequent  eructations,  with  loss 
of  appetite  and  a  foul  tongue,  are  common  symptoms. 
Hsematemesis  or  melaena,  or  both,  may  be  profuse.  The 
absence  of  orderly  development  and  precision  in  the  time 
and  character  of  the  symptoms  makes  the  differential 
diagnosis  between  cirrhosis  and  duodenal  or  gastric  ulcer 
rarely  difficult. 

V.  Splenic  Anaemia 

I  have  known  a  short-circuiting  operation  to  be  per- 
formed in  this  disease.  The  haemorrhage  is  often  very 
abundant.  The  most  copious  haematemesis  I  have  ever 
seen  occurred  in  a  patient  suffering  from  this  condition 
upon  whom  I  was  asked  to  operate  for  duodenal  ulcer.  I 
have  twice  removed  the  spleen  in  cases  of  splenic  anaemia 
from  patients  who  were  sent  to  me  as  cases  of  duodenaJ 
ulcer.     In  both  no  ulcer  nor  any  scar  was  seen. 

VI.  Tabes  Dorsalis 

I  have  seen  five  patients  who  were  operated  upon  in 
this  disease  after  a  mistaken  diagnosis  of  "gastric  ulcer" 
had  been  made.  The  gastric  crises,  and  the  other  dys- 
pepsias seen  in  tabetic  patients,  have  so  Httle  akin  to  the 
symptoms  produced  by  organic  diseases  of  the  stomach 
that  there  is  no  excuse  for  the  mistake.  I  have  had  one 
patient  who,  suffering  from  tabes,  had  also  the  symptoms 
of  duodenal  ulcer.  I  operated  upon  him,  demonstrated 
the  ulcer,  and  performed  gastro-enterostomy. 


GASTRO-ENTEROSTOMY  HJ 

VII.  DISSE^^NATED  Sclerosis 

I  have  seen  one  patient  with  this  disease  upon  whom 
gastro-enterostomy  had  been  performed;  the  surgeon 
found  no  ulcer,  though  the  symptoms  had  suggested  its 
presence  to  him.  In  the  crises  of  the  attacks  of  pain  the 
stomach  became  greatly  distended. 

VIII.  The  Vomiting  of  Pregnancy 

I  have  known  two  patients  submitted  to  the  operation 
of  gastro-enterostomy  for  this  condition  under  a  mistaken 
belief  that  a  gastric  ulcer  was  present  as  the  cause  of  the 
symptoms.  Vomiting  is  neither  a  common  nor,  as  a  rule, 
a  serious  symptom  in  the  great  majority  of  cases  of 
geistric  ulcer. 

IX.  In  Lead  Poisoning 

I  have  seen  one  patient  upon  whom  gastro-enterostomy 
had  been  performed  when  neither  open  ulcer  nor  old 
scar  could  be  found.  The  evidences  of  lead  poisoning — 
colics,  blue  line  on  the  gums,  etc. — were  quite  clear  at  the 
later  stage. 

X.  In  Prolapse  of  Kidney 

Many  years  ago  Sir  F.  Treves  and  Sir  William  Bennett 
described  a  group  of  cases  in  which  a  loose  kidney  had 
pulled  upon  the  gall-bladder  and  ducts  to  such  a  degree  as 
to  cause  jaundice.  The  same  drag  may  be  made  upon  the 
duodenum  and  symptoms  of  pain  and  vomiting  be  pro- 
duced. Loose  kidneys  comparatively  seldom  produce 
symptoms  of  any  consequence,  but  there  is  no  doubt  of 
the  existence  of  the  conditions  just  described. 


118  ESSAYS  ON  SURGICAL  SUBJECTS 

XI.  Colic  Adhesions 

Many  patients  who  suffer  from  vague  dyspepsias, 
ascribed  perhaps  to  intestinal  stasis,  or  to  chronic  appen- 
dicitis, disclose  on  the  operation  table  this  condition: 
A  membranous  band,  broad  above,  where  it  takes  origin 
from  the  posterior  abdominal  wall,  the  under  surface  of 
the  liver,  the  pelvis  of  the  gall-bladder,  the  cystic  duct, 
and  the  duodenum,  narrows  below  as  it  crosses  the  as- 
cending colon  to  be  lost  on  the  peritoneum,  to  the  inner 
side  of  the  ascending  colon,  and  on  the  enteric  mesentery. 
Below  this  band,  which  is  quite  different  from  a  "Jack- 
son's membrane,"  the  caecum  and  the  ascending  colon  are 
distended  and  soggy.  Very  often  the  appendix  looks 
turgid,  thick,  and  stiff.  Removal  of  the  appendix,  to 
which  the  troubles  are  ascribed,  gives  little  or  no  rehef. 
Division  of  the  band  allows  adhesions  to  re-form.  The 
only  practice  likely  to  give  good  results  is  the  removal  of 
the  terminal  ileum,  caecum,  and  ascending  colon.  The 
performance  of  gastro-enterostomy,  of  course,  makes 
matters  worse. 

XII.  Epigastric  Hernia 

A  hernia  of  this  kind,  however  small,  may  cause  teasing 
and  protracted  symptoms.  The  chief  complaint  is  of 
indigestion,  dragging,  heaviness,  etc.  A  careful  examina- 
tion for  this  condition  should  always  be  made. 

B.  THE  OPERATION  HAS  BEEN  INCOMPLETE 

It  appears  to  be  still  a  custom  in  deahng  with  duodenal 
and  gastric  ulcer  to  perform  gastro-enterostomy  only, 
leaving  the  ulcer  itself  untouched,  and  making  no  search 
in  the  abdomen  for  other  conditions.    As  these  ulcers 


GASTRO-ENTEROSTOMY  ii9 

are  probably  often,  if  not  always,  secondary  to  some 
infection  which  may  exist  within  the  abdomen,  such  a 
search  should  be  a  necessary  part  of  every  operation,  pro- 
vided that  the  condition  of  the  patient  will  warrant  it. 
Chronic  appendicitis  is  very  frequently  associated,  prob- 
ably in  a  causal  relation,  with  ulcers  of  the  stomach  and 
duodenum.  It  is  better,  therefore,  always  to  remove  the 
appendix.  The  division  of  the  membrane  which  causes  a 
"Lane's  kink"  may  also  be  practised.  The  gall-bladder 
should  always  be  examined  for  the  presence  of  stones,  or 
of  that  subserous  deposit  of  fat,  especially  near  the  pelvis, 
and  the  cystic  duct,  which  is,  I  hold,  the  first  sign  visible 
from  the  exterior  of  an  infection  of  the  walls  of  the  gall- 
bladder from  within.  Either  the  removal  of  stones  and 
drainage  of  the  gall-bladder  or  removal  of  the  gall-bladder 
may  be  necessary. 

But,  above  all,  the  ulcer  itself  should  be  dealt  with 
in  such  manner  as  to  secure  that  all  large  vessels  running 
into  it  are  hgatured,  and  that  the  risk  of  subsequent 
perforation  is  lessened  or  prevented  by  the  infolding  of 
the  ulcer,  and  by  the  covering  over  of  the  first  part  of  the 
duodenum  by  the  two  omenta.  Cases  of  fatal  haemor- 
rhage from  a  duodenal  ulcer,  weeks  or  months  after  gastro- 
enterostomy had  been  performed,  are  recorded  by  Kocher, 
Quenu,  Sir  F.  Eve,  and  others.  And  Mr.  Corner  has 
related  the  story  of  the  fatal  perforation  of  a  duodenal 
ulcer  in  a  patient  upon  whom  I  had  operated  three  years 
before.  Other  cases  of  perforation  in  similar  circum- 
stances are  known  to  me,  and  some  are  recorded  in  the 
literature.  Merely  to  perform  gastro-enterostomy  in  cases 
of  duodenal  ulcer  is  therefore  to  leave  open  many  chances 
of  subsequent  disaster.  A  direct  dealing  with  the  ulcer  is 
always  necessary.     In  patients  upon  whom  gastro-enter- 


120  ESSAYS  ON  SURGICAL  SUBJECTS 

ostomy  alone  has  been  performed,  there  may  be  a  recur- 
rence of  all  the  original  symptoms  of  duodenal  ulcer.  In 
such  cases  one  of  two  conditions  is  present — either  a 
jejunal  ulcer,  or  a  revival  of  activity  in  the  duodenal  ulcer. 
If  the  latter,  the  infolding  of  the  ulcer,  and  its  protection 
by  a  double  covering  of  the  omenta,  will  remove  the  symp- 
toms at  once.  An  x-ray  examination  before  the  opera- 
tion wiU  probably  show  that  much  of  the  food  passes  by 
the  pylorus.  I  rarely  practise  either  excision  of  the  ulcer, 
exclusion  of  the  pylorus,  or  partial  duodenectomy  and 
gastrectomy  in  cases  of  duodenal  ulcer,  for  the  results  of 
the  simpler  operation  of  gastro-enterostomy  are  hardly  to 
be  improved. 

The  infolding  of  the  ulcer  of  course  narrows  the  pylorus 
for  a  time  at  least,  but  it  is  not  with  the  object  of  pro- 
ducing obstruction  that  the  infolding  is  done.  As  A.  B. 
Mitchell  has  shown,  the  infolded  ulcer  very  rapidly 
disappears. 

C.  DEFECTS  IN  TECHNIQUE 

The  operation  has  been  performed,  rightly  or  wrongly, 
and  certain  technical  errors  cause  distressing  symptoms — 
pain,  vomiting,  diarrhoea,  etc. 

The  chief  of  these  occur  when — 

1. 

The  anterior  or  the  posterior  operation  has  been  per- 
formed, and  a  long  jejunal  loop  has  been  left.  This  loop 
may,  with  difficulty,  be  emptied;  it  may  become  "water- 
logged," and  an  obstruction  may  develop  at  the  afferent 
opening  into  the  stomach.  * 'Regurgitant  vomiting" 
occurs,  only  to  be  reheved  by  lavage,  or  in  severe  cases 
by  the  performance  of  an  entero-anastomosis,  which 
checks  it  at  once. 


GASTRO-ENTEROSTOMY  121 

2. 
With  a  short  or  a  long  loop  the  efferent  piece  of  jejunum 
has  been  blocked  as  a  consequence  of  a  kink,  or  from 
adhesions,  between  the  intestine  on  the  one  side,  and  the 
abdominal  wall,  omentum,  transverse  colon  or  mesocolon, 
and  loops  of  small  intestine  on  the  other.  Regurgitation 
occurs  here  also.  Regurgitant  vomiting  means  high 
intestinal  obstruction. 

3. 

A  short-loop  posterior  gastro-enterostomy  has  been 
performed.  At  the  time  when  the  jejunum  was  lifted  up 
to  oppose  to  the  stomach  before  suture,  adhesions  were 
found  binding  it  to  the  under  surface  of  the  transverse 
mesocolon,  an  exaggeration  of  the  hgament  of  Treitz. 
These  were  divided  and  a  raw  surface  left  on  the  jejunum, 
proximal  to  the  opening  made  to  anastomose  with  the 
stomach.  Adhesions  then  formed  and  caused  obstruction 
of  the  proximal  part  of  the  jejunum  between  the  duodeno- 
jejunal flexure  and  the  opening  into  the  stomach.  Mr. 
Nicoll,  of  Glasgow,  describes  this  condition. 

4. 
The  jejunum  has  been  rotated  round  its  longitudinal 
axis  at  the  time  when  it  has  been  approximated  to  the 
stomach.     This  twist  may  be  quite  enough  to  cause  an 
obstruction. 

5. 

The  opening  is  too  small.  I  have  operated  upon  pa- 
tients suffering  from  pyloric  obstruction  when  a  short- 
circuiting  operation  had  been  performed  a  few  months 
before,  and  have  found  the  opening  too  small  to  admit  the 
tip  of  my  little  finger.  A  gastro-enterostomy  opening 
should  always  be  large;  not  less  than  2^  in.  in  length. 


122  ESSAYS  ON  SURGICAL  SUBJECTS 

6. 

The  opening  is  badly  placed.  The  opening  should 
always  reach  the  greater  curvature  and  is  best  placed  in 
line  with  the  oesophagus.  Whether  the  jejunal  direction 
is  vertical,  as  I  prefer  it,  or  inchnes  from  left  to  right  or 
right  to  left  matters  very  little. 

I  have  found  the  opening,  originally  made  too  small, 
lying  midway  between  the  curvatures,  and  in  one  case 
actually  on  the  lesser  curvature  at  the  incisura.  In  such 
cases  an  a;-ray  examination  will  show  the  existence  of 
a  pool  of  unemptied  stomach  contents  below  the  anasto- 
mosis. By  manipulation  the  stagnant  fluids  can  be 
pressed  out  of  the  anastomotic  opening. 

7. 
The  suture  used  to  eflfect  the  anastomosis  has  em- 
braced not  only  the  cut  edges  of  the  stomach  or  jeju- 
num but  also  a  part  of  the  further  wall  of  either  one  or 
other  or  both  of  these  viscera,  so  that  the  new  opening 
made  between  them  is  much  narrowed.  I  have  found 
this  in  one  case  upon  which  I  did  the  secondary  opera- 
tion for  jejunal  ulcer.  Walton  records  (Proc.  Roy.  Soc. 
Med.,  1920,  XIII,  180). 

8. 
There  has  occurred  a  hernia  of  the  small  intestine 
through  the  unclosed  rent  in  the  mesocolon.  In  one  of 
my  early  cases  (1902)  I  did  not  stitch  the  cut  edges  of 
the  opening,  made  through  the  transverse  mesocolon,  to 
the  suture  line.  A  great  part  of  the  smaU  intestine 
escaped  through  the  opening  into  the  lesser  sac  and  be- 
came strangulated;  the  patient  died.  It  is,  I  think,  im- 
portant to  close  the  opening  in  the  mesocolon  very  care- 


GASTRO-ENTEROSTOMY  123 

fully.  One  of  the  ablest  surgeons  in  the  world  told  me  of 
a  case  in  which  he  did  not  suture  the  opening  very  com- 
pletely, leaving  a  gap  at  the  proximal  end  of  the  jejunum. 
A  small  knuckle  of  bowel  crept  in  and  became  strangu- 
lated. An  operation  on  the  fifth  day  revealed  the 
condition.     The  patient  recovered. 

The  edges  of  the  mesocohc  opening  should  be  sutured 
either  to  the  stomach  or  to  the  suture  hne.  If  they  are 
attached  to  the  jejunum  alone  the  stomach  may  withdraw 
into  the  lesser  sac,  and  so  cause  a  kink  or  obstruction  near 
the  stoma. 

9. 

The  use  of  unabsorbable  sutures — silk,  Hnen,  thread, 
thick  chromicized  catgut.  The  work  of  Wilkie  seems  to 
show  that  catgut  is  to  be  preferred  to  any  other  suture 
material.  It  remains  long  enough  to  ensure  firm  union 
between  the  viscera,  and  disappears  in  a  few  weeks'  time. 
The  catgut  should  be  as  fine  as  is  compatible  with  ade- 
quate strength.  I  use  the  finest  chromic  gut  (000000) 
for  both  sutures. 

In  many  cases  of  haemorrhage  occurring  some  weeks  or 
months  after  the  operation  the  hberation  of  an  unabsorb- 
able suture  may  be  the  cause.  Such  sutures  may  be  seen 
hanging  from  the  fine  of  anastomosis  when  later  operations 
are  performed.  I  have  found  a  piece  of  stout  chromic- 
ized catgut  three  years  and  nine  months  after  the  original 
operation.  Of  the  two  sutures  it  is,  I  beheve,  certain 
that  the  outer  one,  the  sero-serous,  is  the  one  so  long 
retained.  The  inner  stitch,  which  apposes  the  cut  edges 
of  the  mucous  membrane,  is  probably  always  discharged 
within  a  very  few  weeks,  whatever  the  material  of  which 
it  is  composed.  The  use  of  Hnen  and  silk  is  perhaps 
responsible  in  some  degree  for  the  development  of  jejunal 


nU  ESSAYS  ON  SURGICAL  SUBJECTS 

or  gastro-jejunal  ulcers.  The  sutures  have  to  work 
their  way  out,  and  so  delay  healing,  or  start  an  ulcer 
at  any  point.  I  have  twice  found  small  ulcers  near  the 
retained  knot  of  an  unabsorbable  suture. 

10. 
The  anastomosis  has  been  not  seldom  made  with  a 
portion  of  the  intestine  unsuitable  for  this  purpose; 
with,  for  example,  a  loop  of  the  ileum  near  the  ileo-caecal 
junction,  or  even,  as  in  a  case  related  by  Walton,  with 
the  transverse  colon. 

11. 

The  anastomoses  in  two  cases  upon  which  I  subse- 
quently operated  had  been  made  between  the  distal 
pouch  of  an  hour-glass  stomach  and  the  jejunum.  The 
operation  so  far  as  the  mere  junction  of  viscera  was  con- 
cerned had  been  well  done,  but  as  the  obstruction  into 
the  distal  pouch  was  unrelieved  the  operation  did  no 
good  whatever. 

12. 

Ventral  hernia  may  follow  an  imperfect  closure  of  the 
abdominal  wound;  or  after  any  closure  if  there  be  per- 
sistent, severe  coughing  or  vomiting. 

D.  LATE  COMPLICATIONS  MAY  DEVELOP  AFTER  AN 
OPERATION  PERFORMED,  IN  A  CASE  REQUIRING 
IT,  WITHOUT  ANY  TECHNICAL  FLAW. 

1.  Jejunal  Ulcer 

This  is  by  far  the  most  serious  of  all  the  sequels  of 
gastro-enterostomy.  The  ulcer  may  be  at  the  suture  line, 
or  near  it;  it  is  generally  small,  and,  as  a  rule,  is  single. 

Its  causes  are  not  known  with  certainty.  Among  them 
are,  probably,  the  use  of  unabsorbable  sutures,  inaccurate 


GASTRO-ENTEROSTOMY  125 

apposition  of  mucous  membrane,  bruising  of  the  part  of 
the  viscera  embraced  by  clamps  with  the  result  that  a 
hsematoma  fonns,  a  continuance  of  the  cause  of  the 
original  duodenal  or  gastric  ulcer,  and  a  persisting  hy- 
perchlorhydria. 

It  may  at  least  be  said  that  an  avoidance  of  these  faults 
or  treatment  of  these  conditions  will  almost  certainly 
prevent  the  development  of  any  fresh  ulceration.  The 
diagnosis  of  jejunal  ulcer  is  not,  as  a  rule,  at  all  difficult. 
There  are  several  cKnical  types  which  I  have  described 
in  my  book  Abdominal  Operations.  There  are  several 
methods  of  operative  treatment,  not  all  of  them  satis- 
factory and  some  of  them  very  difficult.  Recently  I  have 
performed  partial  gastrectomy  in  such  cases,  removing  the 
stomach  up  to  the  proximal  side  of  the  anastomosis,  and 
all  that  part  of  the  jejunum  engaged  in  the  junction. 

The  proximal  end  of  the  distal  limb  of  the  jejunum  is 
closed  and  the  side  of  it  united  to  the  cut  end  of  the 
stomach;  the  distal  end  of  the  proximal  segment  is 
united  to  the  distal  portion  of  the  jejunum  just  below  the 
anastomosis  with  the  stomach.  I  have  known  jejunal 
ulcer  to  develop  in  two  patients  after  gastro-enterostomy 
performed  in  the  absence  of  any  lesion  in  the  stomach  or 
duodenum. 

2.  Carcinomatous  Change  in  a  Chronic  Gastric  Ulcer 

This  may  occur  after  an  operation  which  has,  for  a 
time,  seemed  perfectly  successful.  I  have  now  in  my 
wards  a  patient  upon  whom  I  performed  gastro-enteros- 
tomy for  chronic  gastric  ulcer  thirteen  years  ago.  At  the 
time  of  the  recent  operation  a  carcinomatous  ulcer  was 
present  at  the  site  of  the  former  simple  ulcer.  In  earlier 
days  I  have  met  with  several  cases  in  which  mahgnant  dis- 


126  ESSAYS  ON  SURGICAL  SUBJECTS 

ease  developed  at  the  site  of  a  chronic  ulcer  after  operation. 
In  the  cases  in  which  the  cancer  is  found  within,  say, 
three  or  four  years  it  may  fairly  be  argued  that  the  growth 
was  present  at  the  time  of  operation,  for  gastric  cancer 
may  increase  very  slowly.  But  in  cases  occurring  later 
than  this  the  great  probability  is  that  the  change  from  a 
simple  to  a  carcinomatous  condition  has  taken  place. 

Nowadays  I  perform,  as  a  rule,  only  two  operations  for 
cases  of  chronic  gastric  ulcer.  If  the  ulcer  is  not  near  the 
oesophagus,  and  is  of  average  or  small  size,  I  perform 
partial  gastrectomy.  If  the  ulcer  is  very  large,  burrowing 
deeply  into  the  liver  or  the  pancreas,  and  near  the  cardiac 
end  of  the  stomach,  I  perform  gastro-enterostomy  in  Y, 
and  into  the  proximal  Hmb  of  the  jejunum,  below  the 
duodeno-jejunal  flexure,  I  introduce  a  tube,  performing 
jejunostomy.  Through  this  tube  the  patient  is  exclu- 
sively fed,  for  few  or  many  months,  until  an  x-ray  ex- 
amination suggests  that  the  ulcer  is  healed. 

In  the  case  of  the  largest  gastric  ulcer  I  have  ever  seen, 
the  ulcer  occupying  the  whole  of  the  lesser  curvature  and 
extending  deeply  into  the  Uver,  the  patient  did  not  take 
one  spoonful  of  food  or  drink  by  the  mouth  for  two  years 
and  nine  months.  I  gave  her  permission  to  do  so  at  the 
end  of  two  years,  when  the  ulcer  appeared  to  be  healed, 
but  she  prolonged  at  her  own  desire  the  period  of  jejunal 
feeding  for  nine  months. 

The  remembrance  of  her  intense  suffering  before  the 
operation,  and  her  perfect  comfort  and  satisfaction  when 
she  took  food  only  by  the  tube,  weighed  with  her  in  making 
this  decision.  The  jejunostomy  opening  has  been  closed 
for  nearly  three  years,  and  she  remains  perfectly  well,  free 
from  pain,  and  is  now  4  st.  heavier  than  when  the  original 
operation  was  performed. 


GASTRO-ENTEROSTOMY  i27 

Symptoms  after  Unsuccessful  Gastro-enterostomy 

The  symptoms  present  in  cases  of  unsuccessful  gastro- 
enterostomy are  chiefly  four — pain,  haemorrhage,  vomiting, 
diarrhoea. 

Pain  may  be  due  to: 

1.  A  revival  of  activity  in  an  unhealed  ulcer. 

2.  The  presence  of  a  jejunal  ulcer. 

3.  Adhesions  cripphng  the  proper  action  of  the 
stomach  or  jejunum. 

4.  The  presence  of  some  other  disease  which  has 
been  overlooked  at  the  operation — chronic  appen- 
dicitis, cholehthiasis,  and  the  other  diseases  enu- 
merated above. 

Haemorrhage  may  be  due  to: 

1.  The  separation  of  a  suture. 

2.  Continuing  activity  in  a  duodenal  or  gastric 
ulcer. 

3.  A  jejunal  ulcer. 

4.  The  presence  of  some  other  disease  which  has 
been  overlooked,  such  as  splenic  anaemia,  cirrhosis 
of  the  hver,  etc.,  as  enumerated  above. 

Vomiting  may  be  due  to: 

1.  Obstruction  as  a  result  of  any  of  those  technical 
defects  in  the  operation  which  I  have  already  named. 

2.  Functional  causes. 

Diarrhoea  may  be  due  to: 

1.  Too  rapid  emptying  of  the  stomach. 

2.  Some  pathological  condition  of  the  intestine,  or 
other  viscera,  which  has  been  overlooked. 

3.  The  offensive  character  of  the  escaping  contents. 


128  ESSAYS  ON  SURGICAL  SUBJECTS 

The  too  rapid  emptying  of  the  stomach  is  sometimes  a 
cause,  or  is  supposed  to  be  the  cause,  of  many  discomforts, 
intestinal  uneasiness  and  turmoil,  and  diarrhoea.  When  a 
patient  sufiFering  in  this  way  is  examined  by  the  a:-ray  the 
stomach  is  seen  to  empty  itself  very  rapidly — perhaps 
in  ten  or  twenty  minutes,  the  food  flowing  through  the 
opening  into  the  intestine  simply  by  the  act  of  gravity. 
In  the  great  majority  of  such  cases  that  have  come  within 
my  own  knowledge  the  operation  of  gastro-enterostomy 
should  not  have  been  performed.  The  stomach  which  acts 
or  fails  to  act,  is  generally  a  feeble,  flabby  atonic  organ, 
capable  of  exercising  little  or  no  control  on  its  contents. 
The  fault  here  is  due  to  the  performance  of  the  operation 
in  an  unsuitable  case.  The  jejunum  below  the  opening  in 
such  cases  appears,  by  aj-ray  examination  and  on  inspec- 
tion, to  be  dilated  as  a  result  of  the  rapid  filling;  its 
distension  may  be  the  cause  of  great  distress. 

As  I  have  said,  pathological  conditions  which  have 
escaped  notice  may  be  the  cause  of  a  continuing  diarrhoea; 
of  such  cases  are  tuberculous  disease  of  the  ileum  or 
caecum,  or  carcinoma  of  the  ascending  colon. 

Diarrhoea  may  also  occur  within  two  or  three  weeks  of 
the  operation,  and  last  a  few  days,  or  even  a  month  or  two, 
rarely  more.  This  is  especiaUy  noticeable  in  cases  of 
malignant  disease  of  the  stomach  causing  obstruction, 
and  is  probably  due  to  the  unchecked  escape  into  the 
intestine  of  putrid  matter  from  the  stomach,  an  intense 
intestinal  irritation  being  the  result. 

In  a  few  patients  upon  whom  gastro-enterostomy  has 
been  performed  with  the  usual  striking  success  an  occa- 
sional attack  of  diarrhoea  may  occur;  the  stools  are  liquid 
and  green  in  colour  and  irritating  to  the  rectum.  In  other 
patients  it  may  be  noted  that  the  stools  are  often  clay- 


GASTRO-ENTEROSTOMY  129 

coloured,  or  almost  colourless.  In  such  cases  the  dis- 
comfort is  trivial  and  temporary,  and  does  not  detract 
from  the  otherwise  excellent  result  of  the  operation. 

Conclusion 

The  enumeration  of  all  these  imtoward  events  in  con- 
nexion with  the  operation  of  gastro-enterostomy  appears 
very  formidable.  But  compared  with  the  excellent  results 
of  the  operation  performed  in  appropriate  conditions,  and 
in  a  skilful  manner,  the  disappointments  are  nowadays 
extremely  few.  Many  of  the  errors  to  which  allusion  has 
been  made  are  probably  things  of  the  past.  For  their 
avoidance  the  greatest  care  in  preliminary  investigation  is 
necessary.  The  diagnosis  of  duodenal  ulcer  is  rarely  diffi- 
cult; the  diagnosis  of  gastric  ulcer  is  never  easy.  A  very 
large  majority  of  patients  supposed  to  be  suffering  from 
"gastric  ulcer"  are  in  truth  suffering  from  other  diseases. 
There  is  only  one  unequivocal  method  of  diagnosis  in  cases 
of  gastric  ulcer,  and  that  is  by  x-ray  examination.  The 
clinical  symptoms  are  very  treacherous. 

But  when  the  operation  is  begun  no  clinical  diagnosis, 
however  confidently  made,  can  stand  against  the  con- 
ditions revealed  then  to  the  hand  and  eye.  If  an  ulcer  is 
not  seen  and  cannot  be  demonstrated,  it  does  not  exist,  and 
therefore  no  operation  designed  for  its  cure  or  rehef  should 
be  performed.  A  search  must  then  be  made  elsewhere. 
And  remembrance  should  always  be  given  to  the  asso- 
ciated and  interrelated  actions  of  such  organs  as  the  Hver, 
spleen,  pgmcreas,  and  the  alimentary  canal. 

REFEaUENCES. 

» British  Medical  Journal,  1910,  i.  p.  241. 


INTESTINAL  STASIS* 

In  a  discussion  upon  "intestinal  stasis"  a  single 
speaker  can  touch  only  very  lightly  upon  any  particular 
aspect  of  this  most  interesting  problem.  The  hterature 
which  has  already  accumulated  is  so  vast,  and  the  claims 
made  as  to  the  importance  of  the  condition  are  so  far 
reaching,  that  anything  in  the  nature  of  a  close  criticism 
of  the  matter  having  regard  to  brevity  is  impossible. 

It  is  asserted:  (a)  that  certain  bands,  webs,  veils,  or 
membranes  are  present  at  defined  points  in  the  alimentary 
canal;  (6)  that  these  adhesions  are  responsible  for  delay 
in  the  onward  transmission  of  the  intestinal  contents,  and 
consequently  for  increased  decomposition  in  them;  and 
further,  that  the  organisms  so  proliferating,  or  other 
noxious  products,  are  absorbed  into  the  system  and  pro- 
duce certain  deleterious  eflFects;  (c)  that  certain  disorders 
are  due  exclusively  to  the  toxaemia  which  comes  from  such 
absorption,  or  from  subinfection,  and  that  a  very  large 
number  of  the  diseases  to  which  man  is  liable  are  also 
harmfully  influenced  thereby. 

What  truth  is  there  in  these  various  statements? 
Of  the  existence  of  various  membranous  adhesions  along 
the  course  of  the  alimentary  canal  there  can  be  no  doubt. 
Between  the  duodenum  and  the  gall-bladder  or  the  under 
surface  of  the  liver,  at  the  duodeno-jejunal  flexure,  at  the 
end  of  the  ileum,  along  the  ascending  colon,  at  the  hepatic 
and  splenic  flexures,  and  to  the  outer  side  of  the  pelvic 

*  Spoken  before  the  Clinical  Congress  of  Surgeons  of  North  America,  London, 
July  31,  1914. 

Reprinted  from  Surgery,  Gynecology,  and  Obstetrics,  February,  1915. 

i3i 


132  ESSAYS  ON  SURGICAL  SUBJECTS 

colon  they  are  plainly  and  frequently  to  be  seen.  There 
origin  is  not  yet  certainly  ascertained,  and  it  may  indeed 
not  always  be  the  same.  Certainly  many  of  them  are 
congenital.  When  in  1899  I  pubhshed  my  work  on 
"Retroperitoneal  Hernia,"  I  had  examined  the  abdomens 
of  a  large  number  of  foetuses,  children,  and  young  adults, 
in  order  to  discover  the  number,  nature,  and  extent  of  the 
peritoneal  fossse.  I  found,  and  there  recorded,  the  fact 
that  adhesions  of  the  proximal  jejunum  and  the  terminal 
ileum  were  not  seldom  found  in  these  case,  and  that  they 
were  due  to  the  condition  described  by  Toldt  as  "physio- 
logical fusion."  The  membreme  which  binds  the  ascend- 
ing colon  so  loosely  to  the  posterior  abdominal  wall — 
Jackson's  membrane,  as  it  is  called,  though  Lane  not  only 
described  but  depicted  it — has  a  vascular  supply  of  such 
regular  appearance  that  it  seems  impossible  that  it  should 
be  anything  other  than  a  developmental  rehc.  The  origin 
of  the  band  at  the  hepatic  flexiu'e,  and  of  the  more  obvious 
and  thicker  string-like  adhesion  at  the  splenic  flexiu'e,  is 
probably,  as  Lane  asserts,  the  result  of  traction  and  the 
effort  to  restrain  or  overcome  its  effects.  Of  the  existence 
of  these  several  membranes,  therefore,  there  is  no  doubt. 
There  is  little  doubt,  also,  that  they  are  for  the  most  part 
congenital  though  mild  inflammatory  processes;  or  the 
response  of  the  parts  to  dragging  force  apphed  to  them 
may  be  responsible  for  their  increased  developemt.  If 
the  supports  of  the  bowel  were  in  need  of  reinforcement  it 
is  probable  that  strength  would  be  added  to  membranes 
already  existing  rather  than  that  entirely  new  bands 
should  be  laid  down.  When  once  these  adhesions  are 
formed  they  may,  of  course,  hamper  the  free  action  of  the 
intestine. 

It  is  often  said  that  in  cases  of  intestinal  stasis  an 


INTESTINAL  STASIS  133 

obstruction  exists  at  the  site  of  one  or  another  of  these 
bands,  and  that  long  delay  of  the  contents  of  the  bowel 
is  caused  thereby.  This  does  not  tally  with  the  general 
operative  experience.  Every  surgeon  who  has  much 
experience  of  the  intestine  in  these  cases  will  agree  that, 
as  a  rule,  the  wall  of  the  gut  is  thin  and  almost  translucent; 
it  is  not,  as  we  see  it  in  cases  of  veritable  obstruction,  thick 
from  hypertrophy  of  its  muscular  wall.  It  is  feebleness 
of  action  rather  than  impediment  which  causes  the  tedious 
transit  of  food.  The  walls  of  the  gut  are  thin,  the  mem- 
branous supports  are  of  such  poor  quaUty  that  parts 
normally  well-fixed  hke  the  splenic  flexure  can  often  be 
withdrawn  from  the  abdomen,  and  the  musculature  of  the 
abdominal  wall  is  flaccid  and  feeble.  Everything  indicates 
that  a  sort  of  apathy  is,  as  a  rule,  the  cause  of  stagnation, 
not  an  obstruction  which  is  with  difficulty  overcome. 

We  may  therefore  take  it  as  proved  that  the  various 
bands  described  in  connection  with  the  intestine  do  exist, 
though  we  may  dispute  as  to  their  origin;  we  may  agree 
also  that  undue  delay  in  the  forward  transmission  of  the 
intestinal  contents  does  occur,  and  that  this  delay  is 
accompanied  either  by  a  form  of  subinfection,  by  organ- 
isms in  varying  degrees  of  attenuation  escaping  from  the 
intestine,  or  by  a  form  of  intoxication. 

What  are  the  chnical  results  of  aU  this?  In  the 
recognition  of  a  certain  type  of  patient  whose  iUs  are  solely 
dependent  upon  intestinal  stasis  we  shaU  aU  probably  be 
in  agreement.  The  victim  of  what  we  may  caU  "Lane's 
disease"  is  now  easily  recognized,  emd  the  symptoms  are 
caused  to  disappear  by  appropriate  surgical  treatment. 
The  symptoms  are  strikingly  repeated  in  case  after  case. 
The  patient  is  generaUy  a  woman  of  unhealthy  aspect 
and  attenuated  figure.     She  is  lean,  cadaverous,  flat- 


i3U  ESSAYS  ON  SURGICAL  SUBJECTS 

chested,  and  she  has  a  sour  breath  and  cold  and  clammy 
hands.  The  skin  is  harsh  and  of  an  earthy  colour  and  bears 
many  crops  of  pimples;  its  secretion  is  apt  to  be  distress- 
ingly noticeable.  She  makes  complaint  of  * 'indigestion," 
pain  after  meals,  flatulence,  and  inveterate  and  incoercible 
constipation.  The  abdominal  muscles  lack  bulk  and 
tone.  They  are  flabby  and  flaccid,  and  all  the  viscera 
which  they  should  hold  up  are  fallen  in  greater  or  less 
degree.  Mentally,  there  is  often  a  complete  absence  of 
the  joy  of  life:  the  patient  is  a  morose,  querulous,  and 
often  suspicious  and  introspective  person.  These  at- 
tributes are  rarely  aU  present  together,  but  so  many  of 
them  may  coexist  as  to  enable  a  distinct  type  of  patient 
tojbe  recognized.  In  the  very  obvious  cases  of  this  kind 
I  do  not  think  the  mild  measures  that  can  often  usefuUy 
be  employed  for  the  novice — massage,  abdominal  exer- 
cises, and  the  unrestricted  use  of  paraffin — are  really  of 
any  value.  These  sufferers  are  property  cases  for  surgical 
treatment.  The  colon  should  be  excised  in  whole  or  in 
part.  In  some,  perhaps,  ileosigmoidostomy  may  be  done ; 
but  in  every  case,  with  one  exception,  in  my  own  series 
there  has  been  some  regurgitation  of  the  intestinal  contents 
upward  along  the  descending  colon  to  the  caecum.  The 
stasis  then  is  worse  than  before,  for  a  mass  of  faecal 
material  that  is  never  wholly  dislodged  is  palpable  at  all 
times.  The  symptoms,  which  are  nevertheless  reheved 
in  great  measure,  are  clearly  not  due  merely  to  the 
stagnation  of  the  bowel  contents.  No  method  of  anas- 
tomosis, nor  any  fashioning  of  new  kinks,  can  wholly 
prevent  this  backward  flow,  though  something  can  doubt- 
less be  done  to  lessen  the  tendency  to  it.  PersonaUy,  I  be- 
lieve that  nothing  short  of  colectomy  offers  a  substantial 
chance  of  cure.    How  much  of  the  colon  is  to  be  removed? 


INTESTINAL  STASIS  135 

This  invites  a  consideration  of  the  function  of  the  large 
gut.  It  is  well  known  that  putrefaction  goes  on  much 
more  largely  in  the  lower  ileum  than  in  the  large  intestine; 
but  it  is  not  improbable  that  in  the  caecum  and  ascending 
colon  absorption  takes  place  more  freely.  The  Hquid 
contents  deUvered  through  the  ileocaecal  valve  are  moved 
backward  and  forward  in  the  ascending  colon  and  rapidly 
lose  a  good  deal  of  the  fluid  matter.  "We  drink  with  the 
large  intestine."  The  ascending  colon  has  possibly  other 
uses:  of  excretion  or  even  of  internal  secretion.  The 
hind  gut,  which  begins  in  some  part  of  the  transverse 
colon  supphed  from  the  anastomosis  magna  of  Riolan,  is 
only  for  the  storage  and  expulsion  of  the  faecal  masses  full 
of  bacteria,  mostly  dead,  deUvered  to  them.  The  part 
of  the  gut  that  needs  removaJ  is  therefore,  I  think,  the  last 
part  of  the  ileum,  the  caecum,  and  the  ascending  colon. 
Accordingly,  in  such  patients  who  need  surgery  I  prefer 
to  resect  these  parts  of  the  bowel. 

It  is,  on  the  whole,  an  advantage  to  have  the  descend- 
ing colon  and  the  pelvic  colon  left.  Absorption  barely 
goes  on  at  all  from  these  parts,  for  we  know  that  a  simple 
injection  of  sahne  fluid  introduced  into  the  rectum  rapidly 
finds  its  way  around  to  the  caecum.  If  the  descending 
colon  and  the  sigmoid  flexure  are  too  lengthy,  a  suggestion 
of  Sir  H.  M.  Gray's  may  be  adopted.  Making  use  of  the 
principles  of  mobiHzation  and  displacement,  to  which  I 
caUed  attention,  he  loosens  the  hind  gut  from  its  moorings 
and  displaces  it  upward;  so  that  what  was  the  pelvic  colon 
becomes  now  the  descending  colon,  and  the  latter  is  made 
to  occupy  the  place  of  the  transverse  colon.  This  opera- 
tion is  simple,  very  satisfactory  in  its  results,  and  in  my 
hands  has,  as  yet,  had  no  mortahty.  Its  advantages 
over  complete  removal  of  the  colon  appear  to  be  that  all 


i36  ESSAYS  ON  SURGICAL  SUBJECTS 

the  maleficent  part  of  the  intestinal  tract  is  removed,  and 
that  enough  of  the  bowel  remains  to  avoid  the  teasing  and 
troublesome  diarrhoea  which  is  known  to  follow  so  fre- 
quently upon  the  larger  operation.  Moreover,  the  num- 
ber of  raw  stumps  of  hgatured  vessels  is  fewer,  and  their 
* 'peritonization"  is  far  more  complete  than  when  all  the 
colon  is  taken.  Finally,  some  of  the  omentum  is  left, 
and  in  a  territory  given  over  at  times  to  riot  the  presence 
of  the  "abdominal  pohceman"  is  possibly  a  witness  to 
peace.  It  is  known  that  a  great  menace,  perhaps  the 
greatest,  attaching  to  the  operation  of  complete  colectomy 
is  the  occurrence  of  obstruction  afterward.  The  raw 
surfaces  left  by  so  great  a  denudation  of  the  posterior 
abdominal  wall,  and  by  the  vessels  which  have  been  tied 
in  the  various  mesenteries,  aJBFord  easy  opportunity  for 
tethering  adhesions  to  form  and  cause  obstruction.  Ileo- 
colic resection  allows  of  very  adequate  "peritonization" 
of  all  the  rough  places  left  and  closure  of  the  gaps  be- 
tween the  divided  ends  of  the  mesentery. 

The  patients  whose  condition  and  appearance  I  have 
just  described  very  often  undergo  a  most  marvellous 
rejuvenation  after  operation.  They  gain  in  weight  and 
glow  with  health;  life  changes  its  colour,  and  vivid  in- 
terest and  keen  enjoyment  succeed  to  apathy  and  lan- 
guor. 

In  deahng  with  the  clinical  aspects  of  intestinal  stasis 
we  are,  so  far,  upon  firm  ground.  We  can  pick  no  quarrel 
with  the  enthusiasts.  What  further  part  does  intestinal 
stasis  play  as  a  causative  factor  in  any  disease?  What 
influence  has  it,  for  example,  upon  the  development  of 
gastric  and  duodenal  ulcer,  and  upon  the  various  phases 
of  cholehthiasis? 

Many  surgeons  have  realized,  and  some  of  us  long  have 


INTESTINAL  STASIS  137 

taught,  that  in  a  great  many  cases  these  common  dis- 
orders of  the  upper  abdomen  are  not  to  be  considered  as 
isolated  and  primary  diseases;  the  view  should  rather  be 
held  that  they  are  secondary  expressions  of  a  primary 
lesion  elsewhere,  and  that  they  are  often  hnked  together 
by  a  common  antecedent,  if  not  evoked  by  a  conmaon 
cause.  There  is  much  evidence  to  show  that  they  are 
secondary  to  some  infection,  within  or  without  the  ab- 
domen. For  some  years  past  I  have  held  the  view  that 
the  appendix  is  the  test-tube  in  which  organisms  are 
propagated  which,  by  a  process  of  subinfection,  express 
their  ravages  in  the  form  of  ulceration  in  the  stomach  or 
in  the  duodenum.  A  gall-stone,  as  we  know,  is  merely 
an  invading  army  of  organisms  coated  by  the  missiles 
with  which  they  have  been  bombarded.  Sir  Arbuthnot 
Lane  beheves  that  the  chronic  inflammation  of  the  ap- 
pendix itself  is  also  secondary — the  result  of  the  causes 
which  are  associated  also  with  stasis  in  the  intestine.  I 
regret  that  I  cannot  accept  his  view  as  tenable,  except 
in  a  small  proportion  of  the  cases.  In  the  great  majority 
we  do  not  find  intestinal  stasis,  nor  the  Lane  kink  or  veil, 
nor,  indeed,  any  of  the  customary  evidences  of  intestinal 
stasis  to  which  he  has  called  attention,  whereas  we  do 
find  the  most  positive  evidence  of  appendicular  disease. 
For  the  last  few  years  when  operating  for  a  chronic 
gastric  or  duodenal  ulcer  or  for  gall-stones,  I  have  made, 
in  all  proper  cases,  a  careful  search  at  the  site  of  the  various 
obstructing  membranes  we  now  so  easily  recognize,  and 
I  am  compelled  to  assert  that  the  evidence  of  stasis,  or  of 
the  demonstrable  conditions  upon  which  it  so  often  de- 
pends, is  not  to  be  found  in  more  than  a  very  small 
proportion  of  the  cases.  Moreover,  the  recovery  of  the 
patient  who,  for  example,  has  had  gastro-enterostomy  done 


i38  ESSAYS  ON  SURGICAL  SUBJECTS 

for  a  duodenal  ulcer,  is  so  speedy,  so  complete,  and  so 
enduring  that  it  is  a  sheer  impossibihty  that  any  hngering 
disease  remains  behind.  We  must  put  this  matter  defi- 
nitely, for  recently  I  have  heard  of  patients  with  de- 
clared duodenal  ulcer  who  have  lost  their  Hves  through 
operations  directed  to  the  rehef  not  of  the  ulcer,  but  of  a 
wholly  suppositious  intestinal  stasis.  For  gastric  ulcer, 
for  duodenal  ulcer,  and  for  cholethiasis  no  operation 
should  be  sanctioned  which  does  not  deal  directly  with 
the  parts  involved.  To  perform  colectomy  or  ileosigmoid- 
ostomy  in  such  cases  is,  I  think,  to  exceed  our  right  and  to 
neglect  our  plain  duty. 

So  far  as  concerns  a  great  variety  of  other  diseases,  it  is 
claimed  that  intestinal  stasis  is  either  the  sole  cause  or  a 
contributory  cause  of  such  significance  that  all  other 
causes  can  be  neglected  or  dismissed. 

In  diseases  of  the  joints,  for  example,  rheumatoid 
arthritis,  or  tuberculous  disease,  stasis  is  held  to  be  the 
essential  indispensable  factor  causing  the  harm,  or  at  least 
permitting  it  to  take  place.  And  the  treatment  of  the 
severer  forms,  at  least,  of  both  diseases  does  not  occupy 
itself  with  a  direct  assault  upon  the  joints  aflfected,  but 
with  the  intestine  from  which  all  the  evil  has  started. 
Cases  are  reported,  and  are  shown  to  us,  in  which  such 
treatment  has  had  an  e£Fect  beyond  all  one's  wildest 
imagining.  I  have  myself  seen  many  cases  of  advanced — 
indeed,  apparently  hopeless — tuberculous  disease  of  the 
hip-joint,  or  of  the  wrist  or  shoulder,  in  which  an  arrest 
of  the  quickly  destructive  processes  took  place  almost  at 
once  when  the  colon  was  removed  or  a  short-circuiting 
operation  performed.  And  a  sensible  improvement  has 
followed  also  in  a  few  cases  of  rheumatoid  arthritis  in 
which,  while  nothing  was  done  directly  to  the  joint,  the 


INTESTINAL  STASIS  139 

whole  colon  was  excised.  Of  the  occurrence  of  such  events 
there  can  be  no  question.  They  do  not,  indeed,  stand 
alone.  Rheumatoid  arthritis,  as  we  all  know,  is  a  disease 
with  many  causes,  with  many  aspects,  with  many  vagaries, 
and  with  many  equal  responses  to  many  different  forms 
of  treatment.  We  know  httle  of  the  disease  except  that 
it  is  often,  possibly  always,  the  result  of  a  chronic  in- 
fective process  at  work  somewhere  in  the  body,  producing 
effects  at  a  distance.  In  the  old  days  of  surgery  the 
earhest  certain  manifestation  in  pyaemia  was  the  affection 
of  distant  joints.  Rheumatoid  arthritis  is  pyaemia  mov- 
ing slowly.  Probably  every  surgeon  knows  something  of 
chronic  joint  diseases  which  undergo  striking  improvement 
when  factories  of  infection  are  closed  down.  I  have  cured 
not  a  few  cases  of  "rheumatoid  arthritis"  by  draining  or 
removing  the  gall-bladder,  which  produced  the  poisons 
to  which  the  joints  reacted.  Of  the  occurrence  of  a  few 
equal  improvements  after  colectomy  I  am  fully  cogni- 
zant; but  I  am  also  aware  of  many  cases  that  have 
showed  httle  or  no  permanent  rehef. 

Of  the  tuberculous  diseases  of  the  joints  the  same  may 
be  said.  Without  question,  there  is  some  improvement 
in  some  cases,  much  improvement  or  even  cure  in  a  few. 
But  the  bulk  of  the  cases,  so  far  as  I  can  judge,  are  not 
appreciably  affected  by  operation  upon  the  intestine. 
Moreover,  I  have  known  of  cases  in  which  tuberculous 
disease  of  the  hip  developed  after  ileosigmoidostomy  had 
been  performed,  and  it  is  at  least  of  some  interest  to 
know  that  a  patient  upon  whom  colectomy  was  done 
fell  a  victim  afterward  to  phthisis,  from  which,  however, 
recovery  took  place. 

The  evidence  at  the  moment  available  allows  us  cer- 
tainly to  say  that  intestinal  steisis  does  seem  to  stand  in 


UO  ESSAYS  ON  SURGICAL  SUBJECTS 

a  causal  relationship  toward  some  cases  of  chronic  joint 
affections,  and  that  such  cases  exhibit  a  marked  and  in- 
stantaneous delay  or  even  cessation  in  the  destructive 
processes,  after  operation  upon  the  bowel,  and  that  a 
complete  recovery  of  the  joint  ultimately  occurs.  What 
is  uncertain  is  not  the  existence  of  such  cases,  but  their 
frequency.  So  little  has  been  done  in  this  direction,  and 
so  few  surgeons  have  lent  themselves  to  this  form  of 
treatment,  that  we  cannot  do  other  than  withhold  a 
confident  opinion.  The  experience  of  the  few,  however, 
is  worthy  of  a  wider  proof  at  the  hands  of  other  surgeons, 
in  carefully  selected  cases. 

But  the  enthusiasts  ask  us  to  travel  with  them  even 
further  than  this.  We  are  told  that  a  very  large  number 
of  diseases  need  have  but  Uttle  attention  paid  to  their 
local  outcry.  This  should  call  attention  not  to  the  seat 
of  pain,  but  to  its  cause,  which  hes  in  the  intestine.  To 
name  a  few  of  these  diseases  is  to  show  the  length  to  which 
we  are  invited  to  go.  Exophthalmic  goitre,  trigeminal 
neuralgia,  various  forms  of  functional  and  organic  disease 
of  the  heart,  diseases  of  the  breast,  of  the  thyroid  gland, 
of  the  pelvic  organs  of  the  female,  and  finally  cancer; 
these  are  only  a  few  of  the  diseases  which  are  due,  it  is 
said,  to  stasis  in  the  intestine.  The  claims  are  many,  the 
proofs  few.  We  ask  for  evidence,  and  if  we  know  some- 
thing of  the  work  that  has  been  done  and  of  the  really 
striking  results  that  have  already  been  achieved,  we  shall 
be  prepared  to  consider  the  evidence,  absurd  though  it 
may  appear  at  first,  with  an  eager  anxiety  to  do  justice  to 
new  views. 

In  medicine  the  new  idea  is  slow  to  gain  currency. 
We  are  a  conservative  race;  and  we  all  find  criticism  a 
more  facile  process  than  creation.    Recent  experiences 


INTESTINAL  STASIS  Ui 

in  more  than  one  branch  of  medicine  will  hardly  persuade 
us  to  change  our  faith.  Too  much  is  claimed  for  every 
new  advance.  Vaccines  were  to  rid  us  of  many  diseases; 
now  the  removal  of  the  colon  is  to  check  all  diseases  that  it 
does  not  cure  outright.  In  the  face  of  such  exaggerated 
pretentions  we  do  well,  perhaps,  to  go  warily ;  but  we  must 
surely  go  with  open  minds.  For  there  is  no  intellectual 
sin  more  deadly  than  sloth  of  the  imagination.  I  have 
thought  many  hours,  read  much,  and  worked  not  a  httle 
at  this  subject  of  intestinal  stasis,  and  have  tried  to  clear 
my  eyes  for  the  new  vision  opened  to  us  by  Sir  Arbuthnot 
Lane.  My  experience  has  been  full  of  surprises:  old 
beliefs,  so  slow  to  perish,  have  been  undermined,  and  new 
faiths,  so  slowly  fashioned,  have  been  painfully  accepted. 
And  now  I  do  not  hesitate  to  say  that  the  whole  question 
is  one  which  will  have  to  be  considered  by  all  of  us  and  to 
be  put  to  the  proof.  It  cannot  be  dismissed  with  a 
shrug  or  a  sneer,  for  there  is  truth  in  the  matter.  .Among 
much  that  is  dross  there  lies  a  nugget  of  pure  gold. 


ACUTE  EMERGENCIES  OF  ABDOMINAL 
DISEASE 

The  subject  of  my  address  to  you  to  day  is  one  which 
has  been  chosen  for  us  by  your  President,  and  the  choice 
has  my  warm  approval.  It  may  perhaps  be  thought  by 
some  that  it  is  aheady  rather  a  hackneyed  one,  that  the 
matter  has  been  so  often  and  so  plainly  discussed  that  httle 
or  nothing  new  or  helpful  remains  to  be  said,  and  that 
hardly  any  further  lessons  remain  to  be  learnt.  If  happily 
that  were  so,  we  should,  I  am  sure,  hear  less  of  the  matter; 
we  should  be  less  often  shocked  by  the  untimely  loss  of  a 
valued  life;  and  the  awful  death-roll  of  abdominal  diseases 
would  be  greatly  curtailed.  It  is  in  medicine  as  in  finance 
— much  poverty  and  much  paper  may  coexist.  It  is  not 
the  settled  problems  of  medicine  about  which  much  is 
written,  it  is  rather  concerning  those  matters  of  which 
many  things  still  need  to  be  made  clear.  And  so  far  as 
this  question  of  the  acute  abdominal  catastrophes  is  con- 
cerned, I  feel  that  we  are  not  yet  in  possession  of  the  real 
secret  of  prevention,  which  is  most  important  of  all,  of 
early  diagnosis  or  even  of  treatment.  There  is  much  that 
has  yet  to  be  written  for  our  admonition;  there  is  still  a 
great  deal  diligently  to  be  learnt. 

The  most  formidable  and  the  most  frequent  of  all  the 
acute  emergencies  in  abdominal  disease  is  concerned  with 
the  vermiform  appendix.  An  acute  attack  of  inflamma- 
tion in  that  organ,  attended  by  gangrene  or  foUowed  by 
perforation,  is  still  the  most  common  cause  of  a  catas- 
trophe, placing  the  life  of  the  patient  in  instant  jeopardy. 

Reprinted  from  the  British  Medical  Journa/,{April  1,  1911. 
i4? 


im  ESSAYS  ON  SURGICAL  SUBJECTS 

and  needing  for  its  certain  and  most  speedy  relief  the 
immediate  intervention  of  the  surgeon.  I  beHeve  firmly 
that  the  serious  characters  and  the  terrible  fatahty  of  this 
disease  are  due  very  largely,  if  not  exclusively,  to  the 
measures  which  are,  with  the  best  intentions  but  with 
profoundest  unwisdom,  directed  to  the  rehef  of  those 
earliest  manifestations  of  the  disease,  the  full  significance 
of  which  is  hardly  yet  appreciated. 

Of  the  functions  of  the  appendix  we  know  almost 
nothing,  but  that  they  are  of  some  real  significamce  is 
probable  from  the  fact  that  the  vascular  supply  of  this 
little  tube  is  considerable  and  apparently  out  of  all  pro- 
portion to  its  size  or  manifest  importance.  The  appendix 
communicates  by  a  valvular  opening  with  the  interior  of 
the  csecum  at  a  point  an  inch  or  more  beyond  the  ileo- 
caecal  valve.  At  this  valve  and  in  the  lowest  part  of  the 
ileum  there  is  a  development  of  the  circular  muscular 
fibres  of  the  intestine  to  a  degree  which  results  in  the 
formation  of  a  sphincter  muscle.  The  anatomical  arrange- 
ment of  the  pyloric  sphincter  with  the  opening  of  the 
diverticulum  of  Vater  at  the  beginning  of  the  small 
intestine  is  in  some  degree  reproduced  here  at  the  begin- 
ning of  the  large,  and,  though  identity  of  architecture 
need  not  mean  similarity  of  function,  it  seems  reasonable 
to  suppose  that  the  glairy  mucoid  secretion  of  the  appendix 
possesses  some  small  digestive  power.  This  function, 
however,  is  not  to  be  condemned  as  trivial  and  without 
value  because  ablation  of  the  appendix  involves  no 
digestive  losses,  for  I  can  recall  more  than  one  case  of 
permement  biliary  fistula  in  the  old  days  when  every  drop 
of  bile  was  discharged  on  to  the  abdominal  wall  and  was 
lost  to  the  economy.  In  spite  of  this,  there  was  no 
apparent  diminution  in  bodily  health  or  weight  or  ca- 


EMERGENCIES  OF  ABDOMINAL  DISEASE         f45 

pacity;  yet  no  one  was  disposed  to  deny  the  value  of  this 
copious  secretion.  Because  we  do  not  know  the  use 
of  the  appendix  and  are  unable  to  measure  its  func- 
tion, we  are  not  rashly  to  condemn  it  as  devoid  of  worth. 
The  position  of  the  appendix  at  the  junction  of  the  small 
and  large  intestine  is  also  noteworthy.  The  small  in- 
testine, as  we  know,  is  concerned  almost  exclusively  in 
the  digestion  and  absorption  of  sohd  matters  from  the 
food.  The  solid  particles  which  are  to  be  absorbed  first  by 
one  side  and  then  by  the  other  of  the  valvulae  conniventes, 
as  they  are  waved  to  and  fro  (and  so  filled  and  emptied)  by 
peristaltic  action,  must  be  kept  in  suspension.  If  fluid 
were  taken  up  in  the  small  intestine  there  would  be  no 
vehicle  for  the  conveyance  of  the  sohd  matter  downwards, 
and  vast  and  various  changes  would  be  needed  in  the 
structure  of  the  alimentary  canal.  It  is  roughly  computed 
that  only  10  per  cent,  of  the  fluid  taken  by  the  mouth  is 
absorbed  before  the  caecum  is  reached.  In  the  ascending 
and  transverse  colon  water  is  freely  taken  up,  and  the 
faecial  residue  is  stored,  tiU  a  convenient  moment  for  dis- 
charge, in  the  sigmoid  flexure.  The  fore-gut  prepares  the 
food,  the  mid-gut  digests  and  absorbs  it,  the  hind-gut 
stores  and  expels  it.  The  mid-gut  extends  from  the  sec- 
ond part  of  the  duodenum  to  the  left  end  of  the  trans- 
verse colon;  and  the  function  is  so  divided  that  the  small 
intestine  appeases  our  hunger,  the  large  intestine  slakes 
our  thirst.  It  is  known  that  fluid  taken  by  the  mouth 
speedily  excites  a  wave  of  peristaltic  activity  in  the  lowest 
ileum.  In  cases  of  typhlotomy  or  of  enterostomy,  in 
which  the  caecum  or  lowest  ileum  is  opened,  it  c£ui  con- 
stantly be  observed  that  the  drinking  of  a  Uttle  fluid 
excites  a  considerable  disturbance  in  this  region.  I  have 
elsewhere  quoted  instances  to  prove  how  excitable  this 

iO 


i^6  ESSAYS  ON  SURGICAL  SUBJECTS 

part  of  the  bowel  becomes  in  response  to  the  swallowing 
of  fluids.  If  the  interior  of  the  caecum  and  the  mouth 
of  the  ileo-caecal  valve  be  visible  (as  in  cases  of  typhlotomy) 
the  increasing  activity  of  the  appendix,  when  water  or 
other  fluids  are  freely  given,  can  be  constantly  witnessed, 
and  never  fails  to  excite  wonder  and  surprise. 

It  has  been  shown  by  Harvey  Gushing,  Gilbert  and 
Domenici,  and  others  that  the  bacteria  in  the  ahmentary 
canal  are  most  numerous  and  of  greatest  activity  at  the 
junction  of  the  large  intestine  and  the  small.  Harvey 
Gushing  has  also  shown  that  starvation  will  render  sterile 
aU  those  parts  of  the  intestine  which  can  be  caused  to 
empty.  On  the  other  hand,  it  is  also  well  proven  that  the 
administration  of  any  aperient  medicine  not  only  excites 
a  greater  tumult  of  activity  in  the  smaU  and  large  in- 
testines, but  that  secretion  is  more  profuse  and  the 
bacterial  virulence  throughout  the  canal  is  considerably 
augmented.  These  points  also  can  be  corroborated  by  the 
examination  of  the  patients  upon  whom  typhlotomy  has 
been  performed.  In  order  that  we  may  see  the  bearing  of 
these  facts  upon  cases  of  appendicitis,  let  me  recount  to 
you  the  type  history  of  a  patient  attacked  by  this  disease. 
The  first  symptom  in  an  attack  of  acute  appendicitis  is 
pain.  It  is  always  pain,  and  never  sickness  or  vomiting, 
nor  malaise,  nor  any  other  symptom  whatever.  If  pain 
should  not  be  the  inaugural  symptom  in  a  case  of  acute 
abdominal  illness,  the  possibihty  of  the  appendix  being  at 
fault  may  definitely  be  excluded.  The  pain  is  absolutely 
abrupt  in  onset,  it  is  of  varying  degree  of  severity,  is  often, 
indeed,  usually  at  first  referred  to  the  epigastrium,  but 
after  the  lapse  of  a  few  hours  becomes,  as  a  rule,  distinctly 
worse  in  the  right  ihac  fossa.  The  pain  may  be  rapidly 
followed  by  a  rigor  or  a  sharp  elevation  in  temperature,  by 


EMERGENCIES  OF  ABDOMINAL  DISEASE         W 

vomiting,  and  frequently  by  diarrhoea.  A  slight  elevation 
of  temperature  occurs  without  exception  in  cases  of  appen- 
dicitis in  the  early  stages.  The  symptoms  one  and  all 
show  a  tendency  to  steady  abatement  if  proper  treatment 
is  adopted,  if  the  patient  is  denied  food  of  all  kinds, 
fluid  or  soUd,  and  if  aperients  are  strictly  and  sternly 
withheld.  It  seems  to  be  the  natural  and  instinctive 
desire  of  the  mother,  wife,  or  nurse  in  such  a  condition 
to  administer  forthwith  a  brisk  purgative.  It  is  held  that 
something  has  "disagreed"  with  the  patient,  and  the 
offending  substance  is  to  be  sharply  expelled.  Castor  oil 
is  the  usual  remedy  in  the  district  where  I  practise,  and 
it  is  administered  unsparingly.  It  is  no  uncommon  thing 
to  be  told  that  because  the  first  dose  was  vomited  (a  most 
proper  act  of  rebelhon  on  the  part  of  the  stomach) 
a  second,  or  it  may  be  a  third,  has  been  given.  A  few 
hours  after  the  aperient  is  swallowed,  frequently  in  the 
early  hours  of  the  morning,  the  patient  is  seized  suddenly 
with  a  new  and  more  intolerable  agony,  vomiting  occurs, 
and  diarrhoea  may  be  repeated.  The  abdominal  wall 
becomes  rigid,  tenderness  spreads  rapidly  across  the  lower 
part  of  the  belly,  and  at  last  is  everywhere  present;  the 
pulse  rises  steadily,  and  all  the  signs  and  symptoms  of  an 
acute  peritonitis  are  ushered  in  without  delay.  When  an 
operation  is  performed,  a  gangrenous  appendix,  very 
probably  adherent  near  its  attachment  to  the  caecum,  is 
found,  and  the  peritoneum,  already  extensively  and 
severely  attacked  by  an  acute  inflammatory  process, 
rephes  to  the  insult  by  pouring  out  freely  a  thin,  clear, 
sterile,  and  actively  bactericidal  fluid.  It  is  now  about 
seven  years  since  I  was  first  brought  firmly  to  the  con- 
viction that  in  cases  of  appendicitis  it  is  the  administra- 
tion of  an  aperient  that  is  responsible  for  the  acute 


f^  ESSAYS  ON  SURGICAL  SUBJECTS 

catastrophe  of  gangrene  and  perforation  which  ends  in  an 
acute  peritonitis.  I  do  not  remember  one  single  case 
that  I  have  operated  upon  since  in  which  it  was  not 
perfectly  clear  that  the  same  sequence  of  events — pain, 
aperient,  perforation — had  occurred,  and  I  therefore  do 
not  hesitate  to  say  that  in  almost  every  instance  of  acute 
peritonitis  due  to  the  perforation  of  an  appendix  it  is 
the  treatment  directed  to  the  rehef  of  the  condition  tMt 
is  the  cause  of  the  serious  and  so  often  fatal  catastrophe. 
The  taking  of  a  purgative  medicine  is  sometlyiig  more 
than  an  impressive  antecedent — ^it  is,  in  my  jiKigement,  a 
definite  cause.  The  only  possible  exceptions  occur  in 
those  rare  cases  where  direct  violence  gives  rise  to  a 
rupture  of  the  appendix  or  the  laceration  of  the  adhesions 
which  enwrap  it.  In  cases  of  appendicitis,  however  acute 
their  origin  may  be,  perforation  followed  by  an  acute 
general  peritonitis  does  not  seem  to  occur  if  no  aperient 
is  given  and  if  absolute  starvation  is  adopted  from  the 
first.  The  acute  spreading  or  general  peritonitis  which 
occurs  in  this  disease  is  due  to  treatment;  it  is  a  "thera- 
peutic peritonitis."  I  am  quite  prepared  to  learn  that 
this  emphatic  statement  is  received  with  a  shrug  of  doubt 
and  the  toleremt  smile  of  disbelief,  but  if  strict  enquiry  is 
made  into  the  intimate  details  of  the  history  of  the  cases 
I  cannot  think  that  my  experience  of  this  disease  will 
prove  to  be  singular.  In  appendicitis  perforation  spells 
purgation. 

The  facts  that  I  have  already  stated  show  that  the 
indications  for  treatment  at  the  onset  of  an  acute  inflam- 
mation in  the  appendix  are  absolute  starvation,  so  that  aU 
peristaltic  activity  in  the  intestine  is  quieted,  and  the 
bacterial  virulence  of  the  contents  of  the  bowel  greatly 
reduced.    The  administration  of  fluids,  which  must  reach 


EMERGENCIES  OF  ABDOMINAL  DISEASE         ili9 

the  caecum  to  be  absorbed,  and  the  turbulent  action  and 
the  high  bacterial  malignity  caused  by  an  aperient  are  to 
be  avoided.  It  is  in  the  caecum  that  bacteria  are  most 
prolific  £uid  most  virulent,  and  the  vast  increase  in  both 
these  quaUties  which  comes  from  the  giving  of  aperients 
is  especially  to  be  avoided  when  the  appendix,  which 
opens  into  the  caecum,  is  inflamed. 

The  theme,  then,  which  I  desire  to  expound  in  this 
connexion  is  that  appendicitis  is  a  disease  which  derives 
its  fiercest  activities  from  the  means  which  are  taken  to 
treat  it;  that  acute  spreading  peritonitis  is  rarely,  if  ever, 
the  result  of  an  untreated  disease,  and  that  it  is  the 
administration  of  aperients  which  transforms  a  simple 
disease  into  one  of  the  most  serious  type.  Peritonitis  so 
arising  is  surely  avoidable;  the  catastrophe  is  the  result  of 
misguided  therapeutic  activity. 

I  have  come  to  the  firm  conclusion  that,  in  spite  of 
the  undoubted  advantages  which  may  in  many  cases 
accrue  from  the  starvation  plan  of  treatment  in  acute 
appendicitis,  early  or  instant  operation  is  always  desir- 
able. If  the  surgeon,  when  he  is  called  in  consultation, 
hears  that  a  purgative  has  been  given,  that  alone  should, 
in  my  judgement,  decide  him  to  advise  an  immediate 
operation.  In  children  especially  there  must  be  no  ex- 
ceptions to  this  law.  An  acute  attack  in  a  child  should 
always  be  treated  surgically,  for  the  usual  signs  £md 
symptoms  present  in  an  adult  are  conspicuously  lacking 
here.  I  make,  and  admit,  no  exception  to  the  rule  that 
in  acute  appendicitis  in  children  urgent  and  early  opera- 
tion is  essential.  And  by  some  means  or  another  parents 
should  be  made  to  know  that  the  dosing  of  children  with 
aperients  is  an  evil,  and  that  they  must  put  a  check  upon 
those  "philo-cathartic  propensities"  which  seem  insepar- 


i50  ESSAYS  ON  SURGICAL  SUBJECTS 

able  from  motherhood.  I  would  like  to  have  the  power 
to  write  in  every  nm'sery  in  the  world  in  large  letters, 
in  the  most  prominent  place,  the  two  words,  "Avoid 
aperients."  Or  perhaps  the  warning  and  appeal  might 
be  brought  home  a  Httle  more  forcibly  in  an  amended 
edition  of  nursery  rhymes: 

Perforation  means  purgation 

With  the  appendix  kinked  and  bad; 
Both  food  and  drink  will  worry  him, 

And  aperients  drive  him  mad. 

To  give  aperients  to  children  who  have  a  "stomach- 
ache" is  homicidal,  yet  so  far  as  I  can  hear  it  hardly 
occurs  to  a  mother  or  nurse  to  do  anything  but  this  the 
most  disastrous  thing  of  all.  While  I  am  speaking  of  this 
let  me  say  that  the  evidence  now  appears  to  me  conclusive 
that  the  "bilious  attacks"  of  children,  accompanied  by 
pain  of  a  griping  or  coHcky  character,  by  vomiting,  occa- 
sionally by  diarrhoea,  by  sUght  fever,  and  by  headache, 
and  ascribed  to  the  greedy  indulgence  in  "indigestible" 
foods,  are  nothing  other  than  mild  attacks  of  inflanunation 
in  the  appendix.  When  an  attack  more  severe  than  all 
the  rest  is  plainly  one  needing  operative  treatment,  and 
the  appendix  is  then  removed,  nothing  is  again  heard  of 
the  recurrent  "bihous  attacks."  In  these  attacks,  how- 
ever, the  appendix  undergoes  certain  changes,  for  in  my 
experience  it  is  rare  to  find  in  operating  upon  cases  of 
acute  peritonitis,  with  gangrene  or  perforation  of  the 
appendix,  that  this  structure  is  free  from  adhesion  or 
obstruction.  It  is  often  difficult  to  deliver  the  caecum 
openly  into  the  wound,  because  adhesion  of  the  base  of  the 
appendix  about  one  inch  from  its  attachment  to  the  intes- 
tine is  so  often  found.  I  beUeve  it  therefore  to  be  the  rule, 
both  in  children  and  in  adults,  that  an  acute  attack 


EMERGENCIES  OF  ABDOMINAL  DISEASE         151 

of  inflammation  of  the  appendix  arises  in  an  organ 
already  diseased  by  reason  of  milder  antecedent  attacks, 
that  perforation  and  the  spreading  peritonitis  which 
it  causes  are  almost  invariably  the  result  of  the  ad- 
ministration of  aperients,  and  are,  accordingly,  pre- 
ventable complications.  There  is  here  only  one  safe 
therapeutic  rule,  and  it  is  "in  all  cases  of  abdominal 
pain,  avoid  aperients."  It  cannot  be  denied  that 
in  some  cases  of  appendicitis  in  which  the  adminis- 
tration of  an  aperient  has  caused  a  perforation  there  is  a 
history  of  one  or  many  attacks  having  been  relieved  by 
the  remedy  which  on  this  occasion  has  led  to  dire  disaster. 
There  is  no  difiiculty  in  accepting  and  appreciating  this 
statement.  For  there  is  Uttle  doubt  that  the  manifesta- 
tions of  appendicitis  are  often  due  to  obstruction  in  the 
lumen  of  this  tube,  and  an  aperient,  by  exciting  an 
increased  activity  of  muscular  contraction,  may  at  one 
time  expel  the  obstructing  material,  and  so  give  rehef,  and 
at  another  time,  being  powerless  to  overcome  the  block, 
may  determine  a  rupture  of  the  waU  of  the  appendix  at 
or  behind  the  point  of  difficulty.  If  the  general  experience 
of  others  should  coincide  in  these  matters  with  my  own, 
the  conclusion  must  be  drawn  that  in  a  very  large  pro- 
portion of  the  cases,  probably  I  think  in  all,  the  serious 
compKcations  of  appendicitis  could  be  prevented  by  a 
timely  recognition  of  the  disease,  by  absolute  starvation 
from  the  first  moment  of  suspicion,  and  by  the  strict 
avoidance  of  aperient  medicines.  But  this  state  of  per- 
fection is  not  yet  within  sight,  and  we  must  accordingly  be 
on  the  watch  for  those  earHest  signals  which  indicate 
that  perforation  has  occurred  and  that  peritonitis  will  be 
swift  to  develop.  The  most  significant  of  all  indications 
is  indubitably  abdominal  rigidity.     If  a  case  of  gangrenous 


152  ESSAYS  ON  SURGICAL  SUBJECTS 

appendicits  is  seen  at  the  very  earliest  stage  there  will  be 
universal  rigidity  and  immobihty  of  the  abdominal  wall, 
but  the  rigidity  is  appreciably  greater  on  the  side  and  over 
the  area  of  the  lesion.  The  earliest  case  of  acute  gan- 
grenous appendicitis  I  have  seen  was  one  to  which  I  was 
summoned  by  Mr.  F.  H.  Mayo: 

P.,  male,  aged  36,  on  January  7th,  1909,  had  a  sudden  attack 
of  slight  abdominal  pain,  which  did  not  abate  during  the  day.  On 
the  morning  of  January  8th  he  was  still  suffering  from  an  aching 
pain  and  discomfort,  and  was  unable  to  take  his  usual  breakfast. 
At  11  o'clock,  as  the  bowels  had  not  acted,  he  took  an  aperient,  and 
a  little  later  a  dose  of  Apenta  water.  During  the  afternoon  he  tried 
to  attend  to  business,  but  had  to  return  home.  At  7  p.  m.  he  took 
a  little  hot  soup,  and  at  7.30  was  seized  with  a  most  agonizing  attack 
of  abdominal  pain,  which  prostrated  him.  His  father,  hearing  him 
cry  out,  went  upstairs  to  his  room  and  found  him  lying  on  the  floor, 
unable  to  raise  himself.  Mr.  Mayo  saw  him  within  a  few  minutes, 
and  I  was  in  the  house  at  8.30  p.  m.  The  patient  was  in  great  pain, 
and  was  huddled  up  on  a  couch,  the  thighs  flexed  on  the  abdomen. 
The  pulse  was  90;  the  abdomen  was  everywhere  resistant,  but 
was  intolerably  sensitive  over  the  right  side.  The  abdomen  was 
opened  in  a  nursing  home,  between  9.30  and  10  p.  m.,  and  the  ap- 
pendix was  found  very  much  swollen  and  injected  in  its  distal  end. 
The  veins  in  the  appendix  and  in  the  mesentery  were  thrombosed. 
There  was  an  obstruction  in  the  lumen  of  the  appendix  about  1  in. 
from  the  caecum. 

This  case  showed  that  the  sudden  onset  of  thrombosis 
of  the  vessels  of  the  appendix,  as  of  the  vessels  in  the 
enteric  mesentery,  is  indicated  by  a  sharp  attack  of 
prostrating  pain,  and  by  the  instant  setting  up  of  a 
barrier  of  firmly  contracted  muscle,  to  act  both  as  a 
protection  and  a  splint. 

The  sudden  onset  of  acute  intolerable  pain  and  the 
development  of  tense  muscular  rigidity  in  the  whole 
belly  wall — these  two  signs  and  these  alone  enable  one 


EMERGENCIES  OF  ABDOMINAL  DISEASE         153 

to  say  that  a  serious  lesion  has  occurred  in  the  abdomen 
which  for  its  most  certain  rehef  will  need  the  interven- 
tion of  the  surgeon.  A  rapid  pulse  is  never  present,  so 
far  as  we  know,  within  the  first  two  or  three  hours;  in 
all  the  very  early  cases  I  have  seen  of  perforation  of  any 
viscus  the  pulse  at  first  was  imder  90.  The  alteration  in 
its  character  and  rapidity  are,  however,  not  long  delayed, 
and  a  steadily  augmenting  rate,  the  pulse  adding  a  few 
beats  more  hour  by  hour,  is  most  significant.  Nausea, 
vomiting,  and  diarrhoea  may  all  be  present,  but  hardly 
add  anything  of  v£due  to  the  other  features  of  the  dis- 
ease. A  strained  and  alert  anxiety  is  noticed  in  the 
expression,  and  the  breathing  is  rapid  and  shallow,  and 
of  the  thoracic  type.  The  diaphragm  is  as  loath  to  move 
as  the  other  muscles  with  which  it  forms  a  wall  around 
the  peritoneal  cavity.  It  is,  however,  never  held  at  first 
in  so  firm  a  contraction  in  cases  of  perforative  appen- 
dicitis as  in  cases  of  rupture  of  the  stomach  or  duodenum 
or  gall-bladder — lesions  which  are,  of  coiu'se,  in  closest 
proximity  to  it.  This  is  another  example  of  the  fact 
that  muscular  rigidity,  though  universal,  is  most  strongly 
developed  in  those  parts  which  are  most  in  need  of  rest 
and  protection. 

The  catastrophe  which  in  point  of  frequency  comes 
next  to  appendicitis  is  concerned  with  the  perforation  of 
an  ulcer  of  the  stomach  or  of  the  duodenum.  Of  these 
ulcers  there  are,  it  is  said,  two  types,  the  acute  and  the 
chronic.  The  acute  is  probably  toxsemic  in  origin,  and 
appears  when  an  infection,  generally  of  an  unusually 
malignant  character,  is  present  in  one  part  or  another. 
In  the  course  of  typhoid  fever,  in  cases  of  burns  and 
scalds,  in  acute  bullous  pemphigus,  in  pneumonia,  in  cases 
of  septic  infections  following  operations  or  independent  of 


f54  ESSAYS  ON  SURGICAL  SUBJECTS 

them,  and  in  erysipelas  and  the  Hke  disorders,  an  acute 
ulceration  of  the  stomach  or  of  the  duodenum,  attended  by 
haemorrhage  and  perhaps  proceeding  to  perforation,  may 
be  found.  The  frequency  with  which  these  ulcers  are 
present  in  all  periods  of  Hfe  is  considerably  underesti- 
mated. For  example,  Helmholz,^  by  devoting  his  atten- 
tion to  the  subject  of  duodenal  ulcer  in  children,  found  in 
six  months  as  many  examples  as  were  contained  in  the 
whole  literature  up  to  that  time.  In  approximately  50 
cases  of  perforating  ulcer  that  I  have  had  under  my  care, 
once  only  has  an  acute  ulcer  been  found.  In  the  rest  the 
ulcer  has  been  of  the  chronic  type,  and  it  has  for  months  or 
years  declared  its  presence  by  the  production  and  perpetu- 
ation of  symptoms  as  to  whose  significance  no  doubt  ought 
to  have  been  felt.  Not  only  does  the  ulcer  which  at  last 
ruptures  into  the  general  peritoneal  cavity  give  clear  and 
sustained  evidence  of  its  presence,  but  in  the  few  days  or 
weeks  preceding  the  final  rent  it  often  declares  its  greater 
activity  and  more  pressing  danger  by  a  considerable  exac- 
erbation in  the  severity  of  the  symptoms. 

It  is  by  degrees  becoming  more  generally  recognized 
that  chronic  ulcers  of  the  stomach  and  of  the  duodenum 
are  conditions  that  can  be  diagnosed  with  an  approxima- 
tion to  accuracy  which,  though  it  leaves  much  to  be 
desired  in  the  case  of  the  former,  is  almost  exact  in  the 
case  of  the  latter.  And  increasing  confidence  is  being 
displayed  in  the  view,  which  some  among  us  have  long 
expounded,  that  chronic  ulcers  are  in  all  cases  in  need  of 
surgical  treatment.  We  may  accordingly  have  reasonable 
expectations  that  with  earUer  and  more  confident  diagnosis 
and  with  a  speedier  resort  to  operative  measures,  the  final 
and  often  long-deferred  catastrophe  of  perforation  in  a 
chronic  ulcer  may  be  wholly  avoided.    Whenever  a  patient 


EMERGENCIES  OF  ABDOMINAL  DISEASE         155 

who  has  complained  at  intervals  of  indigestion  begins  to 
suffer  in  the  present  attack  more  acutely  than  in  an  earher 
one,  the  signal  of  impending  perforation  is  being  raised 
and  the  clear  warning  should  by  no  means  go  unheeded. 

At  the  moment  when  perforation  occurs  there  is  the 
most  agonizing  and  unendurable  pain.  Patients  will 
afterwards  say  that  there  is  no  pain  so  horrible  in  its 
torture  as  this.  The  least  movement  seems  to  add  some- 
thing to  its  severity,  so  that  a  patient  will  perhaps  remain 
for  hours  almost  without  stirring.  A  medical  man  upon 
whom  I  operated  told  me  that  the  perforation  had  occurred 
while  he  was  crouched  on  his  hands  and  knees  in  bed  in  a 
position  which  seemed  to  relieve  his  pain.  When  the 
rupture  of  the  ulcer  took  place  he  could  not  move  to  reach 
the  bell,  and  had  to  wait  motionless  until  help  came  to 
him  in  the  early  morning.  The  tense  rigidity  of  the 
whole  body  is  in  striking  contrast  to  the  ceaseless  un- 
rest of  a  patient  who  is  suffering  the  agony  of  hepatic 
colic.  In  him  a  constant  change  of  position  and  of  pres- 
sure seems  in  some  measure  to  cause  abatement  of  the 
pain,  or,  at  least,  to  be  imposed  upon  the  patient  in  the 
search  for  rehef  that  never  comes.  The  abdominal 
muscles  are  found  to  be  in  a  condition  of  inflexible  rigidity, 
but  even  here  some  difference  in  the  various  parts  of  the 
abdomen  can  be  felt.  Over  the  ulcer  the  stiffness  is  of 
the  most  obdurate  character;  one  might  almost  think  that 
a  disc  of  metal  replaced  the  supple  muscle.  This  local 
increase  of  a  general  resistance  is  most  definite  and  dis- 
tinct, as  a  rule,  and  it  affords  a  decided  help  not  only  in 
the  diagnosis  of  the  lesion  but  in  its  location.  The 
patient's  expression  is  of  one  who  is  terror-struck.  The 
approach  of  a  hand  to  the  abdomen  for  the  purposes  of 
examination  is  quickly  resented,  and  the  most  piteous 


156  ESSAYS  ON  SURGICAL  SUBJECTS 

appeal  for  gentleness  is  made.  The  breathing  is  short, 
jerky,  and  shallow,  and  the  patient  may  indeed  cry  out 
that  he  "cannot  breathe."  This  is  due  in  part  no  doubt 
to  a  spasm  of  the  diaphragm,  and  in  part  also,  I  beheve, 
to  that  great  overdistension  of  the  stomach  which  is  so 
commonly  seen  when  the  abdomen  is  opened.  Though 
the  patient  looks  generally  ill — ^with  paUid  face,  staring 
eyes,  and  sweating  brow — the  pulse  will  be  found  at  the 
first  to  be  hardly  altered  in  frequency  or  in  volume.  This 
is  one  of  the  surprises  which  must  not  fail  to  be  recog- 
nized and  remembered.  I  have  often  been  told  by  medi- 
cal men  that  at  the  first  view  of  a  case  they  could  hardly 
bring  themselves  to  beheve  in  the  occurrence  of  a  perfora- 
tion, since  the  pulse  was  so  tranquil  and  full;  and  in  a 
case  I  saw  some  years  ago  with  Dr.  Carlton  Oldfield,  we 
deliberately  postponed  for  a  few  hours  any  question  of 
operative  treatment  because  the  pulse,  in  rate  and  volume, 
was  normal.  Unhappily,  this  fact  of  the  unaltered  pulse- 
rate  is  even  now  not  generally  recognized;  accordingly 
delay,  which  is  always  serious,  may  occur.  The  pulse 
increases  in  frequency  and  depreciates  in  value  very  soon, 
but  this  is  due  not  to  the  perforation  but  to  the  peritoneal 
contamination  which  is  the  inevitable  sequel.  No  one 
h£is  any  difficulty  in  recognizing  the  presence  of  perito- 
nitis, but  our  aim  must  always  be  to  discover  at  the 
moment  of  its  occurrence  the  lesion  to  which  the  peri- 
toneal infection  is  secondary.  The  symptoms  and  the 
signs  of  the  perforation  of  a  hollow  viscus  are  not  those  of 
the  peritonitis,  which  make  haste  to  develop. 

Among  the  catastrophes  to  which  attention  has  been 
especially  directed  within  recent  years,  the  most  remark- 
able, from  many  points  of  view,  is  that  which  involves  the 
pancreas  in  an  acute  inflammation.    For  some  fime  after 


EMERGENCIES  OF  ABDOMINAL  DISEASE  157 

the  remarkable  paper  by  Dr.  Fitz  in  1889,  the  condition 
of  "acute  hsemoirhagic  pancreatitis"  was  beHeved  to  be 
of  great  rarity;  but,  as  in  so  many  other  cases,  the  recent 
investigations  of  the  surgeon  have  shown  that  infrequency 
of  occurrence  meant  inadequacy  of  observation.  I  have 
operated  upon  11  cases  of  the  most  acute  kind,  and 
7  patients  (the  last  6  in  succession)  have  recovered.  Of 
the  less  acute  cases  which  pass  over  the  initial  stage,  to 
be  operated  upon  some  days  or  weeks  later,  I  have  had 
several  more. 

The  onset  of  pain  in  acute  pancreatitis  is  usually  sud- 
den; a  moment  before  the  patient  may  have  been  going 
about  in  comfort,  conducting  the  ordinary  affairs  of  the 
day.  The  absolutely  instantaneous  onset  of  the  very 
severe  pain  is  constant,  but  some  of  the  patients  will  say 
that  they  have  been  conscious  for  a  few  hours,  or  it  may  be 
for  a  few  days,  of  a  sense  of  discomfort  or  milder  pain  in  the 
upper  part  of  the  abdomen.  About  one-third  of  the  total 
number  of  observed  cases  have  occurred  in  patients  who 
were  the  subject  of  recurring  flatulent  dyspepsia.  The 
patients  are  generally  stout;  women  are  affected  slightly 
more  than  men,  and  pregnancy  would  seem  to  be  a  factor 
of  some  importance  in  the  causation.  The  intense  pain, 
then,  is  sudden  in  onset,  is  confined  within  the  abdomen  to 
the  upper  portion,  but  passes  almost  always  through  to  the 
back ;  it  is  agonizing  beyond  endurance,  and  is  not  seldom 
the  cause  of  fainting  or  a  profound  collapse.  The  face  is 
drawn  and  white,  though  the  hps  are  often  blue.  In 
many  of  the  cases  I  have  seen  there  has  been  a  curious 
leaden  colour  of  the  whole  face,  a  shght  but  unmistakable 
and  I  think  characteristic  cyanosis.  Halsted,  an  early  and 
shrewd  investigator,  pointed  out  that  Hvidity  of  the  face 
and  abdominal  wall  was  often  a  striking  feature  of  these 


158  ESSAYS  ON  SURGICAL  SUBJECTS 

cases.  The  whole  appearance  and  attitude  of  the  patient 
suggest  that  death  may  be  imminent,  for  the  extremities 
are  cold,  the  heart  beats  with  great  rapidity,  and  the 
quaUty  of  the  pulse  is  poor.  Vomiting  is  an  early  symp- 
tom, is  frequently  repeated,  and  may  last  for  days  or 
weeks  if  the  patient  should  survive  so  long.  The  food 
that  has  last  been  taken  is  the  first  to  be  ejected;  after- 
wards all  the  vomited  matters  are  deeply  stained  with 
bile,  and  pure  bile,  to  all  appearance,  may  be  brought  up 
in  large  quantities.  This  has  suggested  in  several  cases 
a  diagnosis  of  high  obstruction  in  the  jejunum.  The 
patient,  as  will  be  grasped  from  this  description,  presents 
the  aspect  and  the  symptoms  of  profound  poisoning;  and 
the  researches  of  Gulecke,  Egdahl,  and  others  make  it 
appear  probable  that  the  toxic  substances  are  produced 
as  a  result  of  the  digestion  of  the  pancreas  by  its  own 
escaped  secretions.  The  abdomen,  when  examined  early, 
presents  the  most  indomitable  rigidity  and  some  fulness 
in  the  upper  part;  the  remaining  parts  may  be  quite  soft 
and  flaccid,  yielding  readily  to  the  hand,  or  they  may  be 
held  with  some  degree  of  firmness.  The  upper  portion 
of  the  abdomen,  the  epigastric  region  especially,  never 
ceases  to  offer  the  most  incoercible  resistance,  and,  how- 
ever gentle  the  examination  may  be,  it  is  grievously 
resented  and  is  repelled  at  the  earhest  occasion.  When 
the  records  of  published  cases  of  acute  pancreatitis  are 
studied,  it  is  seen  that  the  number  that  have  been  cor- 
rectly diagnosed  before  the  operation  is  extremely  small; 
yet  I  am  confident  that  the  symptoms  are  of  such  a 
character  as  to  make  a  recognition  of  their  cause  a 
matter  of  very  httle  difficulty.  Briefly  to  recapitulate, 
there  is,  perhaps,  in  a  patient  inclined  to  stoutness  a 
history  of  antecedent  dyspepsia  which  presents  nothing 


EMERGENCIES  OF  ABDOMINAL  DISEASE         159 

of  the  characteristic  features  of  duodenal  or,  indeed,  of 
gastric  ulceration,  but  which  suggests  rather  the  presence 
of  stones  in  the  gall-bladder,  and  jaundice  may  have 
been  noticed  on  one  or  many  occasions.  The  severe 
pain  comes  quite  suddenly,  is  beyond  the  limits  of  human 
fortitude  to  withstand,  is  associated  with  collapse  of 
a  profound  character,  and  may  cause  the  patient  to 
swoon.  The  hmbs  are  cold,  the  pulse  extremely  poor, 
rapid,  and  thin,  or  even  hardly  to  be  felt  and  not  to 
be  counted.  The  face  may  be  cyanosed.  The  upper 
part  of  the  abdomen  is  exquisitely  tender,  and  all  the 
muscles  there  offer  the  most  resolute  resistance  to  any 
examination.  Vomiting  is  an  early  and  often  a  con- 
spicuous feature.  I  do  not  think  a  group  of  symptoms 
at  all  similar  is  to  be  found  in  any  other  form  of  ab- 
dominal calamity.  There  can  be  no  doubt  that,  as 
in  the  case  of  perforations  of  the  stomach  or  duodenum, 
recovery  may  follow  an  attack  of  acute  pancreatitis. 
Every  now  and  again  I  find  the  evidence  of  this  in  the 
abdomen.  Very  extensive  fat  necrosis  in  or  upon  the 
pancreas,  and  in  its  immediate  vicinity,  is  to  be  seen,  and 
the  pancreas  itself  may  show  the  remnants  of  old  haemor- 
rhages or  contain  a  cyst,  an  abscess,  or  a  slough.  But 
these  occasional  survivals  cannot  impugn  the  fact  that  the 
safest  course  here  also  hes  in  early  operation  upon  the 
lines  first  followed  by  Dr.  Ramsay  of  Bournemouth.  I 
have  recently  operated  upon  a  case  of  acute  pancreatitis 
with  Dr.  Mackhn  of  Whalley,  who  had  the  fortunate 
opportunity  of  seeing  the  patient  within  a  few  minutes  of 
the  onset  of  the  severe  pain.  He  has  kindly  written  for  me 
the  following  very  graphic  account: 

The  patient  was  a  lady,  aged  54,  of  stout  build.    When  sum- 
moned to  her,  about  3  p.  m.  on  December  7th,  1910,  I  found  the 


160  ESSAYS  ON  SURGICAL  SUBJECTS 

patient  verging  on  collapse,  suffering  great  pain,  and  vomiting 
freely.  The  vomit  was  evidently  partially  digested  food  of  which 
she  had  partaken  very  heartily  an  hour  or  two  before.  There 
was  no  relief  from  the  vomiting,  and  the  pain  was  aggravated  on 
assuming  the  recumbent  position,  which  I  induced  her  to  adopt, 
and  aknost  inmiediately  she  had  to  resume  the  semirecumbent  posi- 
tion in  which  I  had  found  her.  From  the  first  the  pulse  was  very 
rapid  and  very  faint  and  the  respiration  very  shallow  and  sighing. 
In  about  a  quarter  of  an  hour  or  so  she  became  almost  pulseless, 
the  features  very  pinched  and  pale,  although  there  was  a  suggestion  of 
cyanosis  in  her  appearance.  At  this  point  ether  was  injected  hypo- 
dennically,  as  she  appeared  to  be  about  to  die.  The  effect  of  this 
was  seen  very  quickly  as  the  pulse  began  to  improve  and  the  col- 
our to  return  to  her  face.  Soon  after  I  had  the  patient  removed  to 
a  couch,  but  she  could  not  assume  the  recumbent  position  with- 
out aggravating  the  pain,  which  had  begun  to  abate  in  some  degree 
by  the  time.  In  the  meantime  the  vomiting  had  diminished  in 
frequency  and  profuseness,  although  from  time  to  time  a  small 
quantity  of  fluid  came  up  which  was  mostly  water  (of  which  she 
drank  from  time  to  time)  stained  with  bile.  Previous  to  my  arrival 
the  patient  had  had  brandy,  and  some  more  was  given  by  my  in- 
structions during  my  brief  temporary  absence  to  procure  the  ether. 
About  two  hours  after  the  beginning  of  the  attack  she  was  removed 
home,  less  than  a  mile  off,  by  motor  and  put  to  bed,  which  had 
previously  been  prepared  for  her  reception.  On  examining  the  ab- 
domen there  was  some  considerable  distension  generally  found,  but 
more  pronounced  in  the  epigastric  region,  where  there  was  great 
tenderness,  so  much  so  that  the  patient  could  hardly  bear  the  sUghtest 
attempt  at  pressure.  The  lower  part  of  the  abdomen  was  very 
flaccid  and  not  at  all  tender.  Pain  continued  very  severe  and  vomit- 
ing continued  more  or  less  frequently,  but  in  all  very  small  quantities. 
The  pulse  became  very  irregular  and  weak  after  the  temporary 
increase  during  which  she  was  removed  home.  The  degree  of  prostra- 
tion continued  so  great  that  I  considered  it  advisable  to  inject  an 
ounce  of  brandy  per  rectum  from  time  to  time  during  the  night. 
About  4  A.  M.  I  left  her,  as  the  severity  of  the  symptoms  had  abated 
somewhat  and  the  pulse  had  become  more  regular  and  stronger,  but  I 
felt  it  safer  to  leave  a  hypodermic  with  ether  and  strychnine  with 


EMERGENCIES  OF  ABDOMINAL  DISEASE         161 

the  nurse  in  case  of  emergency.  At  9  on  Thursday,  the  8th,  I  found 
the  patient  still  complaining  of  much  pain  and  still  vomiting  at 
intervals,  but  otherwise  better,  wherefore  I  injected  ^  grain  of 
morphine,  which  induced  after  a  short  time  a  few  hours'  sleep. 
Towards  nightfall  the  patient  began  to  complain  of  pain  again,  but 
more  of  a  dull  aching  character,  which  was  felt  almost  entirely 
to  the  left  side,  passing  through  to  the  back  and  shoulders.  There 
was  less  tenderness  on  palpation,  the  abdomen  was  still  tense, 
but  no  peritonitis  was  present;  vomiting  recurred,  similar  in  character, 
but  small  in  quantity.  Towards  Friday  morning,  the  9th,  the  char- 
acter of  the  vomit  changed,  and  it  became  more  abundant  in  quantity. 
The  vomit  consisted  of  a  dark  green  looking  fluid  which  had  a  sug- 
gestion of  "coffee  grounds"  about  it. 

At  the  operation  we  found  wide-spread  fat  necrosis, 
especially  in  the  upper  part  of  Morison's  pouch  on  the 
right  side,  an  enormous  enlargement  of  the  pancreas, 
which  was  like  a  phlegmon,  and  a  deep  purple  engorge- 
ment of  the  gall-bladder.  Cholecystotomy  was  performed, 
and  thick  black  bile  drained  from  the  tube  for  two  weeks; 
two  drains  of  rubber  tissue  were  also  passed  down  to  the 
pancreas.     The  patient  made  a  most  excellent  recovery. 

So  far  as  my  own  experience  goes,  the  only  other 

abdominal  emergency  in  which  there  occurs  a  profound 

collapse,  with  instant  lowering  of  the  blood-pressure  and 

a  general  depression  of  the  circulation,  is  dependent  upon 

the  rupture  of  a  tubal  gestation.     But  in  a  number  of 

cases  of  this  condition  which  I  have  treated  I  have  only 

once  felt  any  slightest  doubt  as  to  the  diagnosis,  and  that 

was  in  a  case  which  occurred  twenty  years  ago,  at  a  time 

when  the  diagnosis  of  abdominal  diseases  could  not  be 

made  with  that  confidence  and  accuracy  which  we  possess 

to-day.    The  history  in  cases  of  ruptured  tubal  pregnancy 

is  characteristic.    The  patient  is  generally  between  the 

ages  of  20  and  40,  and  one  menstrual  period  has  been 
u 


162  ESSAYS  ON  SURGICAL  SUBJECTS 

missed.  About  two  or  three  weeks  after  the  time  at  which 
the  period  should  have  occurred  (sometimes,  though 
rarely,  even  later  than  this;  in  one  of  my  cases  over  ten 
weeks  after)  there  is  a  shght  vaginal  discharge  of  blood, 
and  almost  at  the  same  time  an  attack  of  severe  abdom- 
inal pain,  followed  very  speedily  by  pallor,  faintness,  col- 
lapse, air-hunger,  sighing,  restlessness,  and  all  the  symp- 
toms of  great  loss  of  blood.  The  pain  is  acute,  but  does 
not  even  remotely  approach  in  intensity  that  which  is 
present  in  the  conditions  I  have  already  described.  The 
patients,  indeed,  usually  say  that  they  feel  as  if  "some- 
thing had  given  way"  or  as  if  "something  had  burst" 
within  the  body.  The  abdomen  becomes  full,  especially 
in  its  lower  half,  where  a  feeUng  of  tumidity,  of  "doughi- 
ness,"  is  often  present;  and  occasionally  one  side  is  more 
tender  than  the  other.  Resistance  to  the  examining  hand 
is  not  present.  The  muscles,  it  is  true,  may  be  in  some 
degrees  tightened  by  reason  of  the  sudden  increase  in  the 
contents  of  the  abdomen,  but  the  stubborn  and  unchang- 
ing muscular  rigidity  of  the  other  catastrophes  is  never 
present  in  this.  In  a  few  of  my  cases  there  has  been,  as  it 
were,  a  miniature  attack  of  this  kind  before  the  formidable 
and  final  seizure  has  come;  such  are  due,  no  doubt,  to  Httle 
leakings  from  a  tiny  rent,  whose  edges  are  presently 
torn  widely  asunder  to  give  vent  to  the  profuse  bleeding 
which  is  taking  place.  It  is,  I  think,  quite  impossible 
for  any  one  now  to  mistake  this  cHnical  picture  for 
any  other;  the  correct  diagnosis  should  always  be  easily 
possible. 

The  crises  that  develop  in  the  course  of  choleHthiasis 
are  exceedingly  few.  In  more  than  two  thousand  gall- 
stone cases  I  have  only  twice  met  with  a  sudden  rupture 
of  the  gall-bladder,  only  thrice  with  acute  phlegmonous 


EMERGENCIES  OF  ABDOMINAL  DISEASE         163 

cholecystitis,  and  only  once  with  acute  gangrene  with  per- 
foration of  a  common  bile-duct,  which  was  completely  oc- 
cluded by  a  large  stone.    The  attacks  of  hepatic  coUc,  es- 
pecially those  which  are  due  to  the  temporary  impaction 
of  a  calculus  in  the  cystic  duct,  are  terrific  in  severity,  but 
they  are  not  lethal;  the  agony  is  almost  unendurable 
while  it  lasts,  and  the  very  extremity  of  endurance  is 
reached,  but  the  danger  to  life  is  quite  inconsiderable. 
The  acute  cholecystitis  which  results  will  almost  without 
exception  subside  in  the  course  of  a  few  days,  so  that  a 
dehberate  operation  can  then  be  undertaken  with  every 
circumstance  of  care.     That  which  chiefly  distinguishes  a 
patient  suffering  the  torture  of  cohc,  whether  hepatic, 
renal,  or  intestinal,  from  one  in  whom  the  perforation  of  a 
hollow  viscus  has  occurred,  is  his  ceaseless  agitation  and 
unrest.    The  former  patient  tosses  and  throws  himself 
about,  writhes  on  the  floor  or  the  bed,  doubles  and  twists 
himself  in  the  constant  effort  to  get  ease;  the  latter  at  the 
moment  of  the  catastrophe  seems  to  be  struck  motionless, 
and  for  hours  may  be  hardly  able  to  breathe  or  stir.    How- 
ever acute  the  torment  of  hepatic  cohc,  there  does  not  seem 
to  be  any  rigidity  of  the  abdomen  except  in  the  immediate 
region  of  the  gall-bladder.    All  other  parts  are  supple  8md 
free  from  any  tenderness.    A  rigor,  or  a  brief  shudder, 
with  only  a  trivial  increase  of  temperature,  is  seen  not 
infrequently  in  cases  of  incipient  cholecystitis.    When  per- 
foration takes  place  the  temperature  always  faUs.     In  all 
my  hospital  experience  I  have  only  known  one  case  of 
hepatic  cohc  sent  in  as  a  case  of  perforated  gastric  ulcer, 
and  in  that  case  there  was  also  a  subacute  pancreatitis, 
for  when  an  operation  was  undertaken  some  days  later 
recent  evidences  of  fat  necrosis  were  to  be  seen. 

Whenever  the  surgeon  is  caUed  to  see  a  patient  who  is 


16^  ESSA  YS  ON  SURGICAL  SUBJECTS 

believed  to  be  suffering  from  an  acute  abdominal  catas- 
trophe he  must  bear  in  mind  the  possibility  of  the  mimicry 
of  this  condition  by  a  lesion  above  the  diaphragm,  an 
acute  pneumonia,  an  acute  basal  pleurisy,  or  an  acute 
pericarditis.  In  all  these  diseases  in  their  earhest  stage 
there  may  be  severe  pain,  and  some  rigidity  of  the 
abdomen,  more  especially  in  the  upper  parts,  and  the 
resemblance  to  the  conditions  in  an  acute  abdominal 
disease  may  be  very  close.  In  thoracic  diseases  the  res- 
pirations are  quickened  out  of  all  proportion  to  the  rapid- 
ity of  the  pulse  rate.  If  the  respirations  are  more  frequent 
than  one-third  of  the  pulse  rate,  a  pulmonary  lesion  should 
always  be  suspected.  In  thoracic  diseases  there  is  almost 
always  some  elevation  of  temperature ;  in  abdominal  catas- 
trophes there  may  be  a  normal  or  subnormal  temperature. 
In  the  acute  abdominal  conditions  already  described  the 
rigidity  of  the  abdominal  muscles  is  of  the  most  extreme 
degree ;  in  the  thoracic  conditions  there  may  be  stiffness, 
which  is  superficial  and  readily  overcome ;  there  is  Httle 
or  no  tenderness,  and  often  much  rehef  from  a  degree  of 
pressure,  which  if  the  abdomen  were  affected  would  be 
quite  unbearable. 

These  are  the  chief  among  the  various  and  most  serious 
forms  of  calaniity  that  occur  in  connexion  with  diseases  of 
the  abdominal  viscera.  Of  all  such  it  is  true  to  say  that 
they  should  rarely  be  allowed  to  occur.  We  are  now  able 
to  recognize  with  rapidly  increasing  accuracy  the  correct 
interpretation  of  many  symptoms  formerly  ascribed  to 
"functional"  causes.  We  are  quickly  being  brought  to 
realize  that  those  recurring  symptoms  formerly  supposed 
to  indicate  some  vice  in  the  action,  some  change  in  the 
secretion,  or  some  disorder  in  the  sensation  of  an  abdom- 
inal organ,  are  in  reality  due  to  a  perceptible  alteration  in 


EMERGENCIES  OF  ABDOMINAL  DISEASE  i65 

its  structure,  and  that  though  medical  treatment  and  con- 
tinued watchful  care  may  allay  for  a  longer  or  a  shorter 
time  the  symptoms  which  such  organic  diseases  arouse, 
surgical  treatment  alone  is  capable  of  giving  complete 
and  lasting  reUef.  And  so  it  would  appear  certain  that 
by  efficient  treatment  of  the  chronic  disorder  the  acute 
emergency  for  which  it  is  surely  responsible  will  be 
forestalled.  Yet  still  the  need  remains,  not  only  that  we 
should  learn  to  evade  the  catastrophe  whenever  possible, 
but  also  that  we  should  recognize  with  fullest  acciu'acy  all 
those  manifestations  which  swiftly  develop  when  once  the 
crisis  has  occurred.  We  must  free  ourselves  from  the 
tyranny  of  the  text-book,  which  still  chiefly  deals  with 
terminal  events,  and  make  certain  that  we  know  the 
essential  difference  between  the  signs  and  symptoms  of 
the  primary  catastrophe  and  those  of  the  various  compli- 
cations which  finally  develop.  We  must  have  a  concep- 
tion of  abdominal  diseases  which  is  radically  wrong  if  we  do 
not  realize  that  the  exigencies  which  spring  up  so  quickly 
and  prove  so  serious  are  each  one  of  them  a  very  heavy 
rebuke  both  to  our  power  of  early  diagnosis  and  to  the 
resources  of  medical  and  dietetic  treatment. 

Conclusions 

What,  then,  are  the  conclusions  of  the  whole  matter 
that  we  are  entitled  to  draw?  They  are,  I  think,  as 
follows: 

1.  The  catastrophes  which  occur  within  the  abdomen 
are  not,  strictly  speaking,  "acute";  they  are,  on  the  con- 
trary, usuaUy  the  result  of  the  abrupt  transition  from  a 
quiescent  to  an  acute  phase  in  a  disorder  of  long  standing. 

2.  An  acute  emergency  can,  therefore,  be  prevented  by 
a  timely  recognition  of  the  value  and  the  significance  of 


166  ESSAYS  ON  SURGICAL  SUBJECTS 

the  early  symptoms,  so  often  ignored  or  misunderstood,  of 
the  chronic  malady  in  which  it  is  the  final  development. 

3.  The  occurrence  of  a  sudden  attack  of  intolerable 
agony  in  the  abdomen,  associated  with  tense  rigidity  of 
all  the  abdominal  muscles,  indicates  that  there  is  an  acute 
lesion  which  needs  inomediate  surgical  attention.  These 
two  signs,  and  these  alone,  are  an  urgent  warrant  and 
compulsion  to  us  to  treat  the  case  at  once  by  operation. 

4.  A  different  diagnosis  is  generally  possible  if  strict 
attention  be  paid  to  the  details  of  the  aneimnesis,  and  if 
the  finn  abdominal  wall  be  searched  for  a  tender  area  of 
supreme  resistance. 

5.  The  perforation  of  a  hollow  viscus  is  indicated  by 
the  rigid  immobihty  of  the  patient.  CoHc  causes  ceaseless 
unrest. 

6.  Shock  is  not  a  symptom  of  perforation,  for  in  the 
early  hours  after  this  disaster  has  occurred  the  pulse  is 
very  httle  altered  in  volume  or  in  rate. 

7.  In  all  cases  of  abdominal  pain,  especially  in  children, 
the  use  of  aperients  should  be  avoided. 

Reference. 
*  Archives  of  Pediatrics,  September,  1909. 


THE  GIFTS  OF  SURGERY  TO  MEDICINE 

The  annual  address  in  surgery  delivered  before  the 
British  Medical  Association: 

Mr.  President,  Ladies,  and  Gentlemen:  The 
choice  of  the  title  for  the  address  which  I  have  the  high 
honour  to  dehver  must  not  hghtly  be  held  to  indicate  that 
I  admit  any  difference  between  the  essentials  of  medicine 
and  surgery.  The  two  sciences  or  arts  are  not  in  the  re- 
motest particular  antagonistic ;  rather  is  it  true  to  say  that 
they  are  indeed  one  and  indivisible,  and  that  the  separa- 
tion between  the  two  aspects  which  are  presented  to  us  is 
due  to  the  Hmitations  of  the  human  intellect  alone.  It  has 
been  too  long  the  custom  for  surgery  to  be  divorced  from 
medicine,  for  the  problems  of  mind  and  of  hand  to  be  con- 
sidered as  distinct  from  one  another.  Happily,  owing  to 
the  work  which  has  been  done  in  recent  years,  opportuni- 
ties have  abundantly  been  afforded  for  demonstrating  the 
power  of  surgical  research  to  enlarge  the  scope  and  to  en- 
rich the  knowledge  of  many  of  the  problems  of  internal 
medicine.  By  a  study  of  what  I  have  ventured  to  call  the 
"pathology  of  the  hving'*  a  very  profound  change  has  by 
degrees  crept  over  our  knowledge  of  almost  every  form  of 
chronic  abdominal  disorder. 

Post-mortem  Room  Statistics 

In  the  earUer  years  of  the  nineteenth  century  an  ac- 
quaintance with  the  morbid  processes  attacking  internal 
organs  was  based  upon  two  sources  of  information  only — 
upon  an  inquiry  into  the  details  of  the  clinical  history  of 

Reprinted  from  The  British  Medical  Journd,  July  26,  1913. 
i67 


168  ESSAYS  ON  SURGICAL  SUBJECTS 

any  disease  as  it  developed,  waned,  or  progressed,  and 
upon  the  examination  of  the  parts  involved  after  the  death 
of  the  sufferer. 

I  have  endeavoured  to  show,  on  more  than  one  occa- 
sion, how  impossible  it  is  to  measure  the  sufferings  of 
patients  during  their  Uves,  or  to  assess  their  chances  of 
death  from  any  disease,  by  a  consideration  of  the  statistics 
gathered  from  the  post-mortem  room  experience.  People 
do  not  die  in  hospital  from  the  chronic  diseases  from  which 
they  suffer  during  life.  It  is,  so  far  as  the  surgical  side  is 
concerned,  the  acute  terminal  infections,  maUgnant  disease 
in  all  its  forms,  especially  those  lending  themselves  to  sur- 
gical consideration,  and  the  accidents  of  civil  life,  that 
supply  the  bulk  of  the  material  upon  which  the  pathologist 
makes  his  observations.  The  statistics  of  Brinton  and 
Welch,  for  example,  two  of  the  very  ablest  men  ever  en- 
gaged in  medical  work,  upon  gastric  ulcer^statistics  that 
meet  one  at  every  turn  of  the  page  in  the  hterature  of  this 
subject — are,  in  my  view,  almost  without  value.  For  the 
observations  were  not  made  entirely  by  themselves  alone, 
but  by  a  number  of  observers  of  differing  capacity  working 
in  distant  places  under  diverse  conditions.  There  could 
be,  therefore,  no  common  denominator;  there  was  nothing 
by  which  the  values  of  recorded  figures  could  be  made 
equal.  And  it  would  be  futile  to  suppose  that  the  patients 
who  suffer  from  duodenal  or  gastric  ulcer  during  life  are 
adequately  represented,  in  point  of  number,  by  those  who 
die  from  these  conditions  in  the  wards  of  a  hospital,  or  by 
those  in  whose  bodies  the  traces  of  old,  and  perhaps  quite 
inconspicuous,  scarring  or  ulceration  are  discovered.  We 
shall  not,  I  hope,  hear  much  in  the  future  of  post-mortem 
statistics  as  the  guides  or  dictators  of  our  opinions  as  to  the 
maladies  of  the  living. 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  169 

The   Surgeon's  Possibilities   of  Diagnosis  in  the 

Living 

When  the  great  gift  of  America  to  humanity — the  dis- 
covery of  the  anaesthetic  power  of  ether — was  brought  to 
the  aid  of  the  operator,  vast  possibiHties  were  at  once 
apparent  in  the  range  of  the  surgeon's  work.  But  the 
dread  of  infection — indeed,  the  certainty  of  infection — 
held  his  hand  for  more  than  a  generation,  till  the  work  of 
the  greatest  man  our  profession  has  ever  produced,  Lister, 
made  the  dream  of  the  surgeon  come  true,  made  it  possible 
for  him  with  safety  to  carry  through  many  procedures 
which  before  had  been  impossible.  More  than  this,  the 
chance  was  given  to  undertake  the  treatment  of  diseases 
which  had  formerly  run  their  hasty  or  Hngering  course  un- 
checked. Little  by  httle  our  scope  then  widened.  Acute 
conditions  were  at  first  attacked,  perforations  of  the  hollow 
viscera,  gangrene  of  the  appendix,  haemorrhages  from  the 
bursting  of  a  tubal  gestation,  and  so  forth.  By  degrees  the 
impression  grew  that  such  acute  catastrophes  were  but 
final  stages,  terminal  events  in  the  history  of  diseases  whose 
presence  and  course  were  betrayed  by  symptoms  which 
were  clear  and  often  characteristic.  When  these  condi- 
tions were  approached  surgically  in  their  earlier  and  more 
quiescent  periods  the  results  of  operations  were  at  first 
not  very  satisfactory.  Crude  methods  and  imperfect 
technique  left  legacies  of  trouble  behind  them.  The 
mortahty  was  high,  and  remote  results  were  rarely  ideal. 

It  is  interesting  now  to  recall  the  clumsy  manifesta- 
tions which  attended  such  operations  as  cholecystostomy 
or  gastro-enterostomy  in  the  days  of  their  infancy.  Owing 
to  the  labours  of  Senn  and  of  Murphy  simpler  methods 
began  to  find  a  place.     The  bone-plates  and  the  button 


i70  ESSAYS  ON  SURGICAL  SUBJECTS 

showed  how  Kttle  was  really  necessary  to  secure  firm  and 
permanent  imion  between  well-clad  peritoneal  sm-faces. 
Though  these  instruments  are  now  discarded  entirely,  to 
all  of  us  the  lessons  learnt  from  them  were  most  important 
and  most  necessary.  But  for  them  we  should  never  have 
realised  as  we  do  to-day  how  speedily  and  how  simply 
those  manipulations  can  be  carried  through  with  precision 
which  before  had  occupied  two  or  three  hours  and  had 
involved  the  separate  introduction  of  200  or  300  stitches. 
In  surgery  complexity  of  procedure  indicates  defect  in 
method.  The  search  in  all  our  work  is  for  the  simple 
way.  In  surgery,  as  in  other  arts,  simplicity  is  the  supreme 
virtue.  Our  unceasing  efforts  in  technique  are  to  discover 
what  may  seifely  be  left  out. 

The  Association  of  Abdominal  Diseases  Pointing 
TO  A  Common  Cause 

As  we  began  to  recognize,  almost  unconsciously,  the 
ease  and  sufficiency  of  the  simple  mode,  the  mortahty  from 
all  operations  fell  rapidly.  So  it  became  a  safe  and  cus- 
tomary procedure  not  only  to  deal  with  the  particular 
lesion  which  had  demanded  attention  but  also  to  inves- 
tigate the  conditions  of  adjacent  organs.  And  there  sur- 
prising developments  awaited  the  inquirer  and  rewarded 
his  eager  search.  Conditions  other  than  those  which 
needed  immediate  attention  were  found  to  exist  with  no 
little  frequency.  In  diseases  of  the  stomach  or  duodenum 
the  gall-bladder  was  found  not  seldom  imphcated  also;  in 
diseases  of  the  latter,  as  of  the  former,  the  vermiform  ap- 
pendix seemed  often  to  play  the  part  of  an  infecting  agent. 
And  so  by  slow  degrees  the  conviction  was  borne  in  upon 
us  that  these  diseases  I  have  named  did  not  stand  in  rigid 
isolation,  one  separate  entirely  from  the  other,  but  that 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  171 

their  association  was  so  frequent  as  to  indicate  the  strong 
probabihty  of  some  underlying  primary  cause.  Infection, 
it  was  soon  asserted,  whether  carried  by  the  blood-stream, 
by  the  lymphatics,  or  ascending,  as  Bond  has  shown  with 
great  clearness,  along  the  mucous  canals,  was  the  prime 
evil.  Differences  of  opinion  were  soon  declared,  and  still 
continue,  as  to  the  source  of  the  infection.  To  many  of 
us  the  quiescent  inflammatory  lesions  of  the  appendix 
seem  the  most  potent  and  the  most  persistent  of  all. 
Arbuthnot  Lane,  as  I  shall  presently  state  more  fully, 
holds  firmly  to  the  belief  that  the  infections  for  the  diseases 
I  have  named,  as  of  many  others,  have  their  origin  in  the 
intestine,  large  or  small.  And  his  views  are  sustained  by 
him  with  quiet  and  characteristic  courage,  and  with  a 
record  of  results  that  compel  attention  even  from  the  most 
sceptical. 

A  Debt  of  Surgery 

To  the  surgical  assault  we  made  upon  our  patients 
for  the  purposes  of  this  study  of  the  "pathology  of  the 
living"  there  was  one  serious  objection.  After  all  abdom- 
inal operations  some  pain  was  felt.  Not  very  much  in  the 
ordinary  appendix  cases,  a  httle  more  perhaps  in  the  gastric 
cases,  and  certainly  more  in  the  patients  who  had  sub- 
mitted to  operations  upon  the  biUary  tract.  The  pain  was 
rarely  very  severe,  but  it  called  often  for  the  administra- 
tion of  a  small  dose  of  morphine,  and  it  was  certainly 
enough  to  constitute  a  blemish  upon  our  artistry.  Fur- 
ther than  this,  it  was  noticed  that  after  an  operation  in- 
volving a  handling  of  the  parietal  peritoneum,  even  so 
shght  a  manipulation  as  the  separation  and  hgature  of  a 
hernial  sac,  the  patient  complained  of  flatulence,  which,  in 
the  more  severe  cases  of  abdominal  exploration  and  hand- 
Hng,  was  severe  and  most  distressing.     It  had  long  ap- 


f72  ESSAYS  ON  SURGICAL  SUBJECTS 

peared  quite  certain  to  me  that  the  condition  described 
by  the  patient  as  "flatulence,"  the  "gas  pains"  of  the 
American  surgeon,  had  really  little  or  nothing  to  do  with 
gaseous  distension  of  the  intestines.  There  was  a  feeUng 
of  "fullness"  to  the  patient;  but  often  no  recognisable  in- 
flation of  the  intestines  when  an  examination  was  made, 
nor  was  any  real  rehef  obtained  by  the  expulsion  of  gas. 
Flatulence,  I  felt  convinced,  Avas  the  name  given  to  a  con- 
dition which  depended  upon  trauma,  or  the  rough  handhng 
of  the  parts  engaged  in  the  operation.  Happily  we  are 
now  able  to  make  certain  that  any  operative  procedure  in 
the  abdomen  can  be  carried  out  thoroughly  without  the 
infliction  upon  the  patient  of  any  intolerable  pain  and 
without  his  being  caused  to  suffer  severe  flatulent  distress 
afterwards. 

Anoci-association 

Crile  has  enunciated  the  principle  of  "anoci-associa- 
tion." He  has  shown  that  in  the  condition  recognised  as 
"shock"  definite  and  demonstrable  changes  occur  in  the 
cells  of  the  brain,  which  have  discharged  all  the  energy 
they  had  stored.  This  exhausting  discharge  of  nervous 
energy  is  due  to  that  excitation  which  is  caused  by  the 
infliction  of  numberless  injuries,  each  of  them  small,  or  to 
the  infliction  of  one  overwhelming  impression.  When  an 
operation  is  performed  under  ether  anaesthesia,  the  opera- 
tor may  delude  himself  into  the  belief  that  because  his 
patient  lies  unconscious,  and  apparently  unresponsive  to 
any  hurt,  therefore  no  damage  to  his  nerve  centres  is  pos- 
sible. But  ether  anaesthesia  does  not  put  aU  the  brain  to 
sleep;  the  larger  part,  and  by  far  the  more  important  part, 
is  awake  and  staring,  ready  to  be  acted  upon,  and  to  be 
injured,  just  as  easily  as  if  the  patient  were  awake.  The 
fact  that  some  operators  produce  little  constitutional  dis- 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  173 

turbance,  little  shock,  by  the  performance  of  an  operation 
which  at  the  hands  of  another  causes  very  serious  collapse, 
is  not  due  to  differences  in  the  patient,  in  the  anaesthetist, 
in  the  method,  or  in  anything  else  but  the  surgeon  himself. 
There  are  surgeons  who  operate  upon  the  "canine"  prin- 
ciple of  savage  attack,  and  the  biting  and  the  tearing  of  ^ 
tissues  are  terrible  to  witness.  These  are  they  who  oper- 
ate with  one  eye  upon  the  clock,  and  who  judge  of  the 
beauty  of  any  procedure  by  the  fewness  of  the  minutes 
which  it  has  taken  to  complete.  There  are  other  surgeons 
who  believe  in  the  "hght  hand,"  who  use  the  utmost  gentle- 
ness, and  who  deal  lovingly  with  every  tissue  that  they 
touch.  The  former  type  of  operator  is  described  by  Crile 
as  "c£u*nivorous" ;  the  latter  type  is  nowhere  better  ex- 
hibited than  in  his  own  work.  The  scalpel  is,  indeed,  an 
instrument  of  most  precious  use — in  some  hands  a  royal 
sceptre;  in  others  but  a  rude  mattock.  The  perfect  sur- 
geon must  have  the  "heart  of  a  lion  and  the  hand  of  a  lady" ; 
never  the  claws  of  a  lion  and  the  heart  of  a  sheep. 

The  brain,  then,  under  ether  anaesthesia  is  in  great  part 
wide  awake,  appreciative  of  stimuh,  and  in  part  responsive 
to  them.  During  any  surgical  operation,  Crile  assures  us, 
there  is,  in  reply  to  every  incision,  every  pull  of  the  re- 
tractors, indeed  to  every  physical  contact,  a  change  in  the 
pulse,  the  respiration,  and  the  blood-pressure.  Every 
surgeon  conversant  with  abdominal  work  knows  how  a 
rough  handhng  will  cause  tension  in  the  muscles  and 
deepen  the  patient's  breathing,  making  loud  and  stridulous 
the  expiratory  effort,  as  though  the  victim  were  groaning 
in  his  agony.  No  general  anaesthetic,  it  is  clear,  can 
shelter  the  brain  from  the  assault  committed  upon  it  by 
the  injuries  inflicted  during  an  operation.  Crile  has 
therefore  suggested  that  by  means  of  local  anaesthetics — 


17 U  ESSAYS  ON  SURGICAL  SUBJECTS 

novocaine  for  the  skin,  quinine  and  urea  for  the  parietal 
peritoneum — a  barrier  can  be  erected  around  the  area  to  be 
operated  upon,  so  that  no  nerve  impulses  can  be  conveyed 
from  the  territory  so  isolated.  The  field  of  operation,  that 
is  to  say,  may  be  temporarily  disconnected  from  the  brain, 
not  only  at  the  time  of  operation,  but  for  periods  of  one  to 
five  days  subsequently.  The  operation  then  is  conducted 
in  an  area  which,  for  the  time  being,  does  not  belong  to 
the  patient,  which  he  cannot  reach  by  any  impulse  di- 
rected towards  it,  and  which  can  be  dealt  with  as  the 
surgeon  wishes  without  the  patient  having  any  power  of 
receiving  impressions  from  it.^ 

But  this  is  not  all.  Shock  may  be  produced  not  only 
by  physical  violence,  but  also  by  psychical  disturbances, 
by  emotional  excitement,  by  the  receipt,  for  example,  of 
good  or  bad  news  or  by  fear,  the  suspense  and  the  trials  of 
some  great  ordeal.  By  many  patients  their  submission  to 
an  operation  is  viewed  with  dread  and  apprehension.  In 
order  that  the  best  results  should  follow  upon  our  work  it  is 
necessary  that  every  consideration  should  be  shown  to  a 
patient,  and  every  proper  regard  to  his  wishes;  every 
encouragement  should  be  offered,  and  the  impression 
forced  upon  him  that  all  those  engaged  in  the  operation  or 
his  after-treatment  are  working  strenuously  to  the  one  end 
— his  assured  and  rapid  recovery.  The  fears  which  hover 
round  the  last  hour  before  an  operation  are  greatly  modi- 
fied by  the  administration  of  a  small  dose  of  morphine 
with  scopolamine.  A  happy  frame  of  mind  is  thereby 
induced,  and  very  little  nitrous  oxide  gas  is  required  to 
put  the  patient  soundly  to  sleep.  The  memory  of  the 
conveyance  of  the  patient  to  the  operation  theatre  and  of 
the  administration  of  the  anaesthetic  is  often  abolished  by 

1  The  Lancet,  July  5, 1913,  p.  7. 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  175 

these  measures.  This  is,  in  brief,  the  method  of  Crile, 
which  I  have  used  for  many  months,  and  which  has  added 
a  pleasure  to  my  work  that  is  really  immeasurable.  To 
the  great  discoveries  of  Morton  and  of  Lister  this  of  Crile 
seems  to  be  the  fitting  completion. 

Several  interesting  side  issues  have  developed  as  this 
procedure  has  become  more  widely  practised.  The  most 
striking  of  all  improved  results  is  seen  in  the  treatment  of 
exophthalmic  goitre.  In  England  we  see  little  of  this 
disease,  and  very  few  operations  appear  to  be  necessary. 
In  America,  where  the  days  are  more  strenuous  and  the 
rush  of  life  more  eager,  operations  are  more  often  and 
more  urgently  needed.  After  such  operations  it  was  no 
uncommon  thing  to  find  that  the  patient  suffered  pro- 
foundly from  "shock,"  and  the  heart  beat  so  rapidly  that 
it  often  seemed  to  be  galloping  to  death.  After  an  opera- 
tion conducted  by  Crile 's  method  the  emotional  activities 
of  the  patient  are  undisturbed,  and  within  a  few  days  his 
whole  appearance  and  condition  undergo  a  striking  change 
for  the  better.  "Aseptic  wound  fever"  is  almost  certainly 
due  to  psychical  factors. 

Eably  Symptoms  and  Late  Signs 

Equipped  with  these  new  powers,  due  to  the  three  dis- 
coveries of  ether,  ^  of  antisepsis,  and  of  anoci-association, 
the  surgeon  has  been  empowered  to  conduct  his  investiga- 
tions into  the  conditions  of  disease  in  an  entirely  novel 
manner.  Half  a  century  ago  a  patient  who  was  suffering 
from  any  form  of  abdominal  disorder  could  not  do  more 
than  describe  his  symptoms  in  detail  to  his  medical 
attendant.     He  could  not  lend  his  body  to  inquiry,  and  no 

^  I  say  nothing  of  chloroform,  for  I  dislike  and  fear  it  intensely  and  use  it 
hardly  at  all. 


176  ESSAYS  ON  SURGICAL  SUBJECTS 

investigation  of  the  parts  concerned  in  his  disorder  could 
be  conducted  until  after  death.  Death  might  occur  from 
the  final  stages  of  this  same  disease,  or  more  often  from 
some  intercurrent  and  independent  malady.  It  was  diffi- 
cult then  for  the  pathologist  conducting  an  examination  of 
the  body  to  make  the  symptoms  and  the  signs  tally,  for 
at  this  stage  they  had  probably  ceased  to  correspond  one 
to  another.  The  final  ruin  of  an  abbey  tells  us  nothing  of 
the  domestic  habits  of  the  monks  who  found  shelter 
within  its  once  unbroken  walls.  The  ultimate  devasta- 
tion in  a  lesion  of  the  stomach,  such  as  is  seen  on  the 
necropsy  table,  tells  us  nothing  of  any  value  of  those 
early  wanderings  from  the  normal  condition  which  the 
same  parts  had  once  displayed.  Terminal  events  may  seem 
to  have  no  connexion,  or  at  best  a  very  remote  one,  with 
the  early  changes  of  which  they  are  the  outcome.  All  the 
knowledge  our  forefathers  possessed  of  the  pow  er  of  or- 
ganic changes  to  cause  chnical  symptoms  depended  upon 
an  inquiry  into  those  changes  when  they  had  reached  the 
last  stage  in  their  career.  This  last  stage  might  be  disas- 
trous, as  in  the  case  of  a  chronic  ulcer  of  the  stomach  which 
had  led  to  cancer;  or  it  might  be  inconspicuous,  as  in 
the  case  of  a  duodenal  ulcer  which  had  healed,  as  such 
ulcers  sometimes  will,  without  leaving  any  scar,  or  only 
such  as  the  pathologist  in  his  haste  may  overlook.  So 
all  was  confusion.  Two  incompatible  things  were  con- 
sidered side  by  side — early  symptoms  and  late  signs. 
When  we  consider  the  crushing  disadvantages  under 
which  our  forefathers  worked  it  is  amazing  to  find  how 
much  they  did,  gmd  with  what  accuracy  they  had  solved 
many  problems.  The  most  conspicuous  example  of  this 
extraordinary  insight  into  abdominal  diseases  is,  I  think, 
afforded  by  the  work  of  Brinton,  whose  books  on  "Diseases 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  177 

of  the  Stomach"  and  on  "Ulcer  of  the  Stomach"  for  wide 
observation,  profound  and  cogent  reasoning,  and  beauty  of 
language  have  never  been  challenged  by  those  of  any  other 
writers.  But  with  the  new  methods  to  which  I  have  re- 
ferred the  study  of  the  pathology  of  the  living  became 
possible.  Symptoms  recited  at  the  moment  could  be 
ascribed  to  the  lesion  disclosed  by  the  operation  in  the 
precise  stage  of  its  existence  in  which  it  was  capable  of 
arousing  those  symptoms.  The  history  of  abdominal 
surgery  in  the  last  ten  years  is  the  tale  of  the  lessons  that 
were  learnt. 

The  most  considerable  revolution  has  occurred  in  con- 
nexion with  our  inquiry  into  the  condition  of  "dyspepsia." 
To  any  who  have  no  acquaintance  with  their  works  I  can 
hardly  imagine  a  greater  intellectual  dehght  than  to  read 
what  Brinton,  Johnson,  Sir  Thomas  Watson,  and  other 
early  fathers  have  written  upon  the  subject  of  dyspepsia. 
With  perfect  accuracy  of  observation  in  many  instances, 
with  supreme  mastery  of  EngHsh  in  almost  all,  they  tell  the 
story  of  many  of  the  forms  of  dyspepsia.  But  none  of 
them  realised,  as  we  by  degrees  have  come  to  learn,  that 
dyspepsia  is  so  often  a  manifestation  not  of  a  nervous  or 
functional  disorder,  but  of  a  real  organic  change.  The 
story  of  how  this  all  came  about  may  bear  retelling. 

In  the  early  days  of  gastric  surgery  operations  were 
undertaken  either  for  the  reUef  of  patients  afflicted  with 
carcinoma,  after  the  methods  laid  down  by  the  great  pio- 
neer and  master,  Billroth;  or  for  the  treatment  of  cases 
of  pyloric  obstruction  by  the  operation  of  gastro-enteros- 
tomy,  suggested  in  a  whisper  by  Billroth's  assistant,  Nico- 
ladoni.  Of  cancer  I  have  at  this  moment  nothing  to  say. 
In  cases  of  pyloric  obstruction  the  operation  gave  results 
which  were  quite  amsizing  in  their  character  and  rapidity. 

i2 


i78  ESSAYS  ON  SURGICAL  SUBJECTS 

Patients,  emaciated  almost  to  the  last  degree,  unable  to 
take  more  than  the  most  meagre  of  meals,  afflicted  with 
copious  vomiting  at  intervals  of  only  a  few  days,  became  in 
two  or  three  weeks  happy  mortals,  with  keen  relish  for 
food,  which  gave  no  unease,  and  which  was  retained  with- 
out difficulty.  Many  patients  underwent  a  veritable 
resurrection;  one  of  my  patients  weighed  51  lbs.  when 
operated  upon  and  a  few  years  later  weighed  131^  lbs., 
and  in  several  instances  I  have  known  the  weight  to  be 
doubled. 

"Gastric  Ulcer"  in  the  Right  Iliac  Fossa 

So  marvellous  were  these  results  that  the  eager  activity 
of  surgeons  led  them  to  employ  the  same  method  in  other 
cases  of  "gastric  ulcer."  Patients  who  for  years  had 
suffered  the  misery  or  the  martyrdom  of  indigestion 
readily  submitted  to  any  operation  offering  a  prospect 
of  relief.  But  it  soon  became  apparent  that  the  results 
were  not  so  briUiant  in  the  later  as  in  the  earUer  cases, 
and  the  dreadful  mistake  was  widely  made  of  accepting 
the  diagnosis  of  "gastric  ulcer"  as  positive  in  all  patients 
who  presented  the  symptoms  which  the  text-books  of 
medicine  had  told  us  were  pathognomonic  of  the  disease* 
Patients  who  suffered  from  pain,  vomiting,  and  haemat- 
emesis  were  held  to  be  the  victims  of  "gastric  ulcer," 
and  for  gastric  ulcer  the  approved  surgical  remedy  was 
gastro-enterostomy.  Little  by  little  the  truth  dawned 
upon  us  that  "gastric  ulcer"  was  a  perilous  diagnosis  to 
make.  For,  with  whatever  confidence  the  existence  of  this 
lesion  was  predicted,  disappointment  and  dismay  followed 
fast  upon  the  investigation  of  the  parts.  The  stomach  in 
these  cases  often  showed  no  trace  of  that  hard  white  scar 
which  we  knew  must  indicate  the  site  of  an  ulcer  of  old 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  179 

standing.  For  a  long  while  we  were  at  a  loss  to  know  what 
the  cause  of  the  symptoms  might  be,  when  all  the  stomach 
walls  and  the  duodenum  appeared  healthy.  The  scope  of 
inquiry  in  such  patients  was  therefore  widened,  and  the 
discovery  made  which  excited  the  deepest  disbeUef  in  the 
minds  of  many  and  which  still  meets  with  increduhty — 
the  discovery  that  in  the  majority  of  cases  which  come  to 
£ui  operation  a  "gastric  ulcer"  has  its  place  in  parts  other 
than  the  stomach. 

There  is  now  no  longer  any  doubt  in  my  own  mind 
that  the  commonest  site  of  a  "gastric  ulcer"  is  in  the  right 
ihac  fossa.  That  is  to  say,  that  in  the  majority  of  cases  in 
which  the  most  erudite  teaching  of  the  most  astute  Ger- 
man physicians  would  justify  or  compel  a  diagnosis  of 
ulcer,  the  patient  is  suffering  from  a  lesion  elsewhere,  and 
more  often  than  not  from  a  lesion  in  the  appendix.  The 
appendix  may  present  a  variety  of  conditions,  but  they  are 
all  alike  in  one  particular — they  are  all  obstructive  in 
character.  Infection  and  obstruction  together,  or  apart, 
as  Sir  Bertrand  Dawson  has  well  said,  make  all  the  ills 
from  which  a  patient  derives  abdominal  trouble.  In  the 
appendix  both  may  be  at  work  at  the  same  moment;  in- 
deed, one  follows  inevitably  upon  the  other.  In  my  ex- 
perience there  is  no  appendicitis  without  obstruction.  In 
these  cases  of  mimicry  of  gastric  ulcer  is  the  stomach, 
then,  quite  healthy?  In  my  earher  and  less  complete 
observations  I  often  thought  it  was.  Now  I  feel  sure  that 
there  is,  I  think  I  may  say  always,  such  a  change  in  the 
appearance  of  the  organ  as  will  enable  the  most  absolute 
prediction  to  be  made  that  the  appendix  is  diseased. 
These  changes  are:  a  vivid  injection,  a  deep  congestion  of 
the  pyloric  portion  of  the  stomach  over  a  distance  of  two 
or  three  inches  at  least;  a  great,  irregular,  eager  activity  of 


180  ESSAYS  ON  SURGICAL  SUBJECTS 

contraction,  the  muscles  of  the  part  appearing  to  writhe  in 
angry  contortions;  and  thirdly,  an  enlargement  of  the  sub- 
pyloric  group  of  glands.  The  explanation  of  these  changes 
is,  I  think,  now  clear;  of  their  existence  there  is  no  longer 
any  doubt.  The  present  position  of  oiu*  opinion  is  ac- 
cordingly this,  that  in  many  of  the  cases  of  "gastric  ulcer," 
the  symptoms  of  which  are  pain,  flatulence,  acidity,  heart- 
burn, vomiting,  and  haematemesis,  the  lesion  primarily 
responsible  for  such  symptoms  does  not  he  in  the  stomach. 
The  lesion  is  one  in  which  infection  and  obstruction  are  in 
league  to  do  harm,  and  its  most  frequent  location  is  in  the 
appendix. 

The  evidence  seems  to  be  increasing,  and  is,  indeed, 
already  abundant,  in  favoiu-  of  the  view  that  these  distant 
infections,  whether  in  the  appendix  or  elsewhere,  which 
often  produce  the  gross  lesions  just  described  in  the 
stomach,  may  be  the  precursors  and  the  excitants  of  a 
chronic  ulcer  of  the  stomach.  The  experimental  work  of 
Turck,  Bolton,  and  Wilkie  has  shown  how  ulceration  of 
the  gastric  mucosa  may  be  set  up  by  infecting  agents, 
and  may  be  perpetuated  by  the  inabihty  of  the  stomach 
completely  to  empty  itself  in  the  normal  time.  To  infec- 
tion, stasis  is  added  and  often  also  an  increased  acidity,  or 
at  least  an  acrimony  of  the  gastric  juice.  Gastric  ulcer, 
then,  would  appear  to  be  almost  always  a  secondary  dis- 
order; the  primary  fault  hes  not  in  the  stomach,  but  else- 
where, its  expression  is  manifest  in  the  stomach  because  of 
the  particular  series  of  incidents  which  occur  therein.  This 
much  is  certain — that  when  cases  of  gastric  ulcer  come  to 
the  operation  table  the  evidence  of  other  and  apparently 
older  lesions  is  rarely  wanting. 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  181 

Chronic  Ulcer  and  Carcinoma 

Among  the  most  notable  of  the  gifts  of  sm*gery  to 
medicine  is  the  proof  that  in  a  large  proportion  of  cases 
the  onset  of  cancer  of  the  stomach  is  not  a  new  and  mi- 
accountable  thing,  but  is,  on  the  contrary,  a  tardy  devel- 
opment upon  an  earlier  condition  which  for  years  had 
clamoured  for  recognition.  It  appears  to  me  that  the 
work  of  the  Mayo  Chnic  has  offered  irrefragable  proof  of 
this  assertion. 

I  am,  of  course,  well  aware  that  all  cases  of  cancer 
of  the  stomach,  unhappily,  do  not  come  to  the  surgeon. 
No  one  but  the  surgeon  can  do  any  good  to  patients  so 
affhcted.  Yet  there  is  a  strange  timidity  of  approach  to 
the  sxu'geon  which  is  unaccountable,  and  far  too  often  the 
favourable  period  in  the  history  of  a  case  is  allowed  to  slip 
away  before  any  recognition  of  the  real  condition  is  at- 
tempted. It  is  true,  then,  and  must  be  admitted,  that 
when  the  surgeon  speaks  of  the  work  which  passes  under 
his  hand  he  is  not  speaking  of  the  whole.  Nor  is  anyone 
else.  Neither  the  physician  nor  the  post-mortem  inves- 
tigator knows  the  whole  range  of  cases;  indeed,  each  sees 
far  less  nowadays  than  the  surgeon.  The  view  of  the 
latter,  therefore,  if  not  all-embracing,  is  doubtless  wider 
than  that  of  anyone  else.  The  experience  of  the  surgeon 
shows — and  here  geographical  considerations  seem  to 
matter  Uttle — that,  roughly,  two  out  of  three  of  all  pa- 
tients who  come  for  reUef  from  a  condition  of  carcinoma 
of  the  stomach  give  a  history  of  inveterate  and  recurring 
dyspepsia  over  a  stretch  of  many  months  or  years.  No 
one  knows  so  well  as  the  surgeon,  for  he  made  and  repeats 
daily  the  discoveries,  that  such  a  history  does  not  mean 
that  there  is  a  chronic  ulcer  of  the  stomach,  healing  and 


182  ESSAYS  ON  SURGICAL  SUBJECTS 

breaking  down  afresh,  during  all  that  time.     But  though 
we  are  grown  chary  of  making  a  diagnosis  of  "gastric 
ulcer"  with  that  ease  and  certitude  which  formerly  at- 
tached to  the  physicians  of  all  countries,  we  can  and  do 
make  an  accurate  diagnosis  in  a  large  proportion  of  the 
cases,  if  only  those  patients  are  allowed  to  be  suffering 
from  "gastric  ulcer"  who  can  hardly  be  supposed  to  be  the 
victims  of  any  other  organic  lesion.     The  surgeon  who 
walks  by  sight  and  not  by  faith  knows  that  a  gastric  ulcer 
is  a  real  thing,  though  so  many  imposters  have  claimed  his 
attention.     In  the  majority  of  the  cases  of  gastric  car- 
cinoma the  history  given  of  earher  attacks  makes  it  almost 
certain  that  these  were  due  to  a  veritable  ulcer  of  the 
stomach.     There  may  be,  I  fully  admit,  errors  in  this 
estimate;  but  making  all  the  allowances  that  our  operative 
experience  warns  us  to  be  necessary,  there  can  be,  I  tliink, 
no  doubt  at  all  that  a  genuine  clironic  gastric  ulcer  has 
been  the  cause  of  that  dyspepsia  of  which  recurring  at- 
tacks are  noted.     In  one  of  these  attacks,  perhaps  after 
an  interval  of  months  or  years  of  freedom,  something  dif- 
ferent is  noticed.    The  attack  is  heralded  in  the  old  way; 
at  first  no  difference  between  it  and  the  others  may  be  ob- 
served.   But  by  degrees  it  is  reaHsed  that  something 
worse  is  occurring.     The  symptoms,  which  in  earher  at- 
tacks were  so  easily  amenable  to  careful  treatment,  to  rest, 
to  sparing  diet,  and  so  forth,  have  now  become  more  severe 
and  incoercible.    ReUef  does  not  come  from  the  measures 
which  before  have  been  so  instantly  successful.     More- 
over, weight  is  more  rapidly  lost,  anaemia  may  develop, 
and  anorexia  is  most  persistent  and  distressing.     This  is 
the  occasion,  all  other  and  more  favourable  occasions  hav- 
ing lapsed,  when  instant — it  can  hardly  be  called  preco- 
cious— surgical  treatment  should  be  urged.    The  patient 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  183 

has  now  arrived  at  middle  life,  or  has  passed  it,  and  the 
diagnosis  of  cancer  may  tentatively  be  made  and  should 
be  acted  upon  with  alacrity.  Surgical  intervention  for 
purposes  of  inquiry  has  hardly  any  mortahty  nowadays. 
If  a  cancer  be  found  and  a  resection  of  the  stomach  is 
undertaken,  the  mortahty  will  vary  with  the  expertness 
of  the  hands  which  practise  it.  But  whatever  that  mor- 
tahty may  be,  it  cannot  attain  the  death-rate  of  inaction 
and  of  "expectant"  or  medical  treatment,  which  is  ex- 
actly 100  per  cent.  It  was  urged  by  Dr.  W.  L.  Rodman 
many  years  ago  that  resection  of  the  pyloric  end  of  the 
stomach  for  the  ulcers  that  singly  or  in  clusters  are  found 
there  was  the  most  prudent  mode  of  treatment.  In  his 
chnic  at  Rochester  Dr.  W.  J.  Mayo  has  for  several  years 
resected  the  stomach  not  only  for  chronic  ulcers  in  the 
vicinity  of  the  pylorus  but  also  for  those  tumours  which 
might  be  due  to  ulcer  or  might  be  due  to  cancer,  for  de- 
clared cancer  and  for  those  cancers  which,  though  evi- 
dently not  curable  because  of  the  enlargement  of  distal, 
secondary  glands,  or  other  visceral  deposits,  were  yet  re- 
movable. In  his  so  safe  hands  resection  has  hardly  any 
greater  mortahty  than  gastro-enterostomy.  This  pro- 
cedure is  questionless  the  ideal  one.  It  has  afforded,  of 
course,  a  unique  series  of  specimens  for  investigation. 
Dr.  Wilson  and  Dr.  MacCarty  conclude  from  their  ex- 
amination of  all  the  material  so  furnished  that  in  71  per 
cent,  of  these  cases  of  cancer  of  the  stomach  the  mahgnant 
process  is  engrafted  upon  a  simple  one,  that  cancer  is 
really  due  to  a  secondary  change  which  starts  in  the  edge 
of  an  ulcer  of  long  standing.  My  own  material,  far  less 
in  quantity,  bears  out  their  contention.  It  has  been 
shown  that  in  the  base  of  these  ulcers  tending  to  cancer 
the  mucosa  has  gone,  leaving  only  scar  tissue ;  in  the  over- 


18U  ESSAYS  ON  SURGICAL  SUBJECTS 

hanging  border  of  the  ulcers  the  mucosa  is  proliferating, 
and  some  epithelial  cells,  nipped  off  by  scar  tissue,  are 
showing  all  the  stages  of  aberrant  proliferation  with  in- 
filtration of  the  surrounding  tissues  and  metastases  in  the 
lymphatic  vessels  of  the  stomach  wall.  The  truth  of  these 
observations  is  hardly  yet  admitted  by  those  whose  in- 
quiry has  been  based  only  upon  specimens  found  in  the 
post-mortem  room  or  on  the  shelves  of  the  museums— 
upon  parts,  that  is,  that  have  been  long  dead,  and  sub- 
jected, no  doubt,  to  the  many  changes  which  death  and 
swift  decay  bring  in  every  cell.  Upon  the  post-mortem 
table  only  the  final  dilapidated  ruin  of  the  disease  is  seen ; 
in  specimens  removed  during  fife  the  disease  in  its  earher 
stages  can  be  scrutinised.  The  material  upon  which  the 
pathologist  has  formerly  worked  has  not  been  favourable 
to  the  discovery  of  the  truth;  the  sources  of  eternal  truth 
were  poisoned. 

It  would  be  hard  to  decide  among  so  many  strong  com- 
petitors as  to  the  primacy  of  any  piece  of  work  given  out 
by  the  Mayo  Clinic.  It  is,  however,  safe  to  say  that  the 
real  and  permanent  value  of  the  contributions  to  this  sub- 
ject of  cancer  of  the  stomach,  both  from  the  technical  and 
the  pathological  sides,  can  hardly  be  overstated. 

Duodenal  Ulcer 

The  infection  which  has  its  origin  in  the  appendix  or 
in  the  intestine  wreaks  other  harm  than  that  upon  the 
stomach  waU.  Of  duodenal  ulcer  and  of  cholehthiasis  we 
have  also  learnt  that  they  are  usually  secondary  manifesta- 
tions. Of  duodenal  ulcer  I  have  so  recently  and  so  fully 
written  that  it  is  not  necessary  here  to  do  more  than  record 
the  fact  that  a  full  knowledge  of  its  symptoms  and  course, 
and  the  power,  unrivalled  in  any  other  abdominal  dis- 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  185 

orders,  of  making  an  accurate  diagnosis  are  not  the  least 
important  of  the  gifts  of  surgery  to  medicine.  Of  this 
disease  ahnost  nothing  was  learnt  after  enquiry  from  the 
dead  alone,  except  of  those  late  preventable  disasters  which 
come  from  its  unchecked  course.  In  the  early  days  of  our 
recognition  of  this  condition  we  were  assailed  by  a  for- 
midable array  of  post-mortem  statistics  which  went  to 
show  the  rarity  of  the  disorder,  and  the  absence  or  the  in- 
constancy of  any  symptoms  which  could  be  attributed  to  it 
during  the  hfe  of  the  patient.  We  now  know  the  great 
frequency  of  the  disease — every  month  I  operate  upon 
more  cases  than  were  formerly  recognised  in  the  post- 
mortem room  of  the  largest  hospitals  in  ten  years — and  the 
claim  may  truthfully  be  made  that  of  all  abdominal  dis- 
eases none  can  be  more  certainly  discovered  by  a  scrutiny 
of  the  anamnesis  alone. 

The  Etiology  of  Gall-stones 

Another  and  equally  important  reversal  of  opinion  has 
occurred  in  connexion  with  choleHthiasis.  It  was  for- 
merly the  accepted  behef,  and  as  fallacies  die  hard  may  still 
be  the  view  of  some,  that  in  a  large  percentage  of  cases 
gall-stones  were  "innocent";  they  declared  their  presence 
by  no  apparent  sign,  and  their  existence  threatened  no 
peril  to  the  health  or  life  of  the  patient. 

The  work  of  Lartigau  upon  the  etiology  of  gall-stones  is 
of  the  first  importance.  He  showed  that  active  organ- 
isms taken  up  by  the  portal  stream  from  the  intestine  were 
passed  through  the  hver,  which  acted  as  a  "destructor." 
They  emerged  from  it  in  the  bile,  lifeless.  Some  few,  how- 
ever, under  special  circumstances,  made  their  escape,  and 
remained  active  in  the  bile  which  flowed  to  the  intestine. 
If  the  organisms  which  find  their  way  into  the  gall-bladder 


186  ESSAYS  ON  SURGICAL  SUBJECTS 

are  violent  in  their  activities  an  acute  inflammatory  con- 
dition, of  a  degree  which  varies  with  the  intensity  of  the 
infection,  is  caused.  There  may  be  any  gradation  from  an 
acute  phlegmonous  cholecystitis  to  a  trivial  and  evanes- 
cent catarrhal  condition  of  the  mucosa.  If  the  germs  be 
in  an  attenuated  condition  the  contractile  power  of  the 
gall-bladder  is  competent  to  expel  them,  and  no  harm  re- 
sults. So  far  as  experiment  serves  to  show,  a  stone  can 
only  develop  in  the  gall-bladder  (and  the  gall-bladder  is 
the  factory  wherein  all  stones  are  made)  if,  with  a  miti- 
gated culture  of  micro-organism,  there  is  some  retarda- 
tion of  the  outflow  of  bile.  Sepsis  and  stasis  must  go  to- 
gether. The  gall-bladder  then  puts  forth  its  own  efforts 
to  protect  itself,  and  secretes  cholesterin,  which  being  de- 
posited upon  the  surface  of  the  germs,  clumped  as  they 
probably  are,  safely  immures  them.  A  gall-stone,  then, 
consists  of  a  deposit  of  cholesterin  (alone,  or  with  the  addi- 
tion of  other  salts)  upon  a  nucleus  of  organisms  which  have 
intruded  into  the  gall-bladder.  Every  gall-stone,  as  I 
have  said  before,  is  a  tombstone  erected  to  the  evil  memory 
of  the  germs  that  lie  dead  within  it.  The  frequency  with 
which  gall-stones  he  inert  within  the  gall-bladder,  causing 
no  harm  and  arousing  no  symptoms,  is  so  very  smaU  as  to 
be  quite  negligible.  It  is  certainly  much  less  than  1  per 
cent,  in  aU  those  cases  which  come  for  surgical  treatment, 
and,  though  I  admit  that  this  estimate  involves  a  possible 
fallacy,  yet  the  truth  cannot  be  known  of  all  the  cases  in 
which  gaU-stones  exist,  for  neither  operative  work,  nor  the 
examinations  of  the  dead,  nor  the  records  of  the  "spas,'* 
reveal  the  whole  matter. 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  187 

The  Inaugural  Symptoms  of  Gall-stones 

The  error  that  has  found  a  place  in  the  minds  of  all 
medical  men,  and  has  been  faithfully  carried  down  from 
one  generation  of  text-books  to  another — that  in  the 
majority  of  cases  gall-stones  cause  no  symptoms — has 
been  forever  dispelled  by  the  work  of  the  surgeon.      In 
operating  upon  cases  of  advanced  cholelithiasis  a  history 
of  inveterate  though  perhaps  trivial  dyspepsia  over  a  long 
period  can  almost  always  be  obtained.     In  operating  upon 
patients  for  the  relief  of  other  conditions — ^myoma  of  the 
uterus,  ovarian  or  other  pelvic  conditions,  appendicitis,  or 
ulcer  in  the  stomach  or  duodenum — a  routine  examination 
of  the  gall-bladder  and  kidneys  should  be  made.     Every 
now  and  again  stones  will  be  found  in  the  gall-bladder, 
and  far  more  rarely  in  the  kidneys.    In  the  case  of  the 
former  a  clear  history  of  dyspeptic  troubles  can,  in  my 
experience,  invariably  be  obtained.     It  is  true  that  these 
symptoms  are  not  those  which  are  commonly  recognised 
as  being  due  to  a  gall-bladder  condition,  but  the  gift  of 
surgery  to  medicine  consists  here  in  the  true  portrayal 
of  those  cHnical  manifestations  which  only  an  examina- 
tion of  the  Hving  could  disclose.     We  now  know  that  the 
earliest  symptoms,  the  "inaugural  symptoms,"  of  chole- 
hthiasis  are  just  as  characteristic,  just  as  certainly  to  be 
recognised,  as  those  of  the  later  sequels  and  avoidable 
comphcations.     And  more  than  this:   the  very  httle  that 
was  known  of  cholelithiasis  in  its  clinical  aspects  has  un- 
dergone a  complete  revision,  with  the  result  that  we  are 
often  able  to  declare  not  only  the  presence  of  stones,  but 
often  the  position  of  that  which  is  causing  the  most  serious 
trouble.    The  only  circumstances  under  which  symptoms 
are  not  at  the  moment  aroused  by  stones  which  lie  within 


188  ESSAYS  ON  SURGICAL  SUBJECTS 

the  gall-bladder  exist  when  the  cystic  duct  has  become 
permanently  closed  and  the  walls  of  the  gall-bladder, 
thick,  and  white,  and  hard,  embrace  firmly  the  stones  that 
he  harmless  within  it.  This  is  the  "natural  cure"  of 
Rutherford  Morison,  a  condition  which  develops  only  after 
months  or  years  of  symptoms,  often  of  great  severity.  It 
is  Nature's  cholecystectomy,  and  though  Nature  may  be 
an  admirable  physician,  her  skill  as  a  surgeon  is  of  the 
lowest  order,  and  her  work  cumbersome,  clumsy,  and 
dangerous. 

Lesions  of  the  Pancreas 

It  is  as  an  outcrop  of  the  work  of  the  surgeon  on  gall- 
stones that  all  our  modern  knowledge  of  the  chnical  aspects 
of  chronic  pancreatitis  has  sprung.  The  acute  form  of 
pancreatitis  was  first  recognised  and,  with  something 
nearly  approaching  to  finahty,  described  by  one  of  the 
greatest  of  physicians — Dr.  Fitz  of  Boston.  But  of 
chronic  inflammation,  of  stone,  of  cysts,  and  of  the  mim- 
icries of  cysts  nothing  was  heard  or  known  till  the  sur- 
geon came  bearing  these  gifts  in  his  hands. 

We  know  well  the  great  change  that  comes  over  all 
parts  of  the  body  after  death;  the  face  changes,  wrinkles 
are  smoothed  away,  the  cheeks  sink  in,  the  eyes  are  lustre- 
less, the  orbits  hollow.  Other  parts  change  equally,  and 
among  them  the  pancreas,  perhaps,  most  of  all.  In  a 
case  of  acute  pancreatitis  the  gland,  at  the  moment  of 
operation,  seems  one  massive  phlegmon — tumid,  doughy, 
and  with  no  abrupt  margin.  After  death  it  appears  to 
be  merely  a  bruised  and  blood-stained  organ.  So  with  the 
gland  in  a  state  of  chronic  inflammation.  To  the  hand  of 
the  operator  it  may  feel  large  and  densely  hard,  and  it  may 
be  responsible  for  the  obstruction  and  a  considerable  dila- 
tation of  the  common  bile-duct.    After  death  it  seems 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  189 

hardly  altered  from  the  normal,  and  certainly  in  earlier, 
less  exact  days  would  not  have  attracted  close  attention. 
The  evidence  of  the  operator  and  the  pathologist  was  then 
incompatible,  because  neither  seemed  to  recognise  that 
their  approach  to  the  problem  w£is  from  different  points 
of  view. 

The  question  of  chronic  pancreatitis  was  first  brought 
before  the  minds  of  surgeons  by  Riedel,  who  noticed  that 
in  many  operations  upon  the  biUary  passages  the  pancreas 
was  large,  hard,  and  unduly  firm.  In  three  recorded  cases 
he  believed  the  patient  to  be  suffering  from  carcinoma  of 
the  head  of  the  gland,  and  he  gave,  accordingly,  a  hopeless 
prognosis.  Two  patients  recovered,  and  remained  per- 
fectly well;  the  third  patient  died,  and  the  examination  of 
the  pancreas  showed  no  trace  of  maHgnancy,  but  the  plain 
evidences  of  a  chronic  interstitial  inflammation.  Little 
knowledge,  however,  sprang  from  this  observation,  until 
Mayo  Robson,  with  his  then  unrivalled  experience  of  chole- 
hthiasis,  showed  the  frequency  and  the  cUnical  importance 
of  pancreatitis,  and  convinced  us  all  of  its  powers  of 
mimicry  both  of  carcinoma  and  of  the  calculous  form  of 
common  duct  obstruction. 

Its  mimicry  of  carcinoma  may  be  complete.  Pain- 
lessly and  progressively  the  patient  may  develop  jaundice, 
which  continues  to  deepen  until  the  "black  jaundice"  of 
the  older  writers  can  be  recognised.  There  is  great  loss 
of  weight  and  prostration,  hebetude  and  misery,  though 
often  the  appetite  is  unimpaired.  The  liver  enlarges  and 
the  gall-bladder  distends  to  a  degree  which  allows  it  to  be 
easily  seen  and  felt  protruding  below  the  rib  margin.  In 
accordance  with  the  law  of  Courvoisier  we  assume  that 
such  a  dilatation  of  the  gall-bladder  is  due  to  causes  other 
than  stone.    An  examination  of  the  stools  might  show  a 


i90  ESSAYS  ON  SURGICAL  SUBJECTS 

complete  absence  of  bile  pigment,  and  this  may  seem  the 
most  conclusive  evidence  of  carcinoma,  for  a  chronic  in- 
flammation, however  inveterate,  rarely  causes  an  abso- 
lutely impermeable  block  to  the  passage  of  bile. 

Cholecystenterostomy 

With  the  history  of  a  condition  such  as  this,  one  could 
hardly  fail  to  make  a  diagnosis  of  growth  and  predict  a 
speedy  ending  to  the  case.  But  no  one  Uving  is  infaUible 
in  the  differential  diagnosis  of  obstructive  jaundice.  The 
diagnosis  is  always  so  difficult,  and  the  chance  of  a  life 
saved  so  important,  that,  however  positive  the  evidence  of 
mahgnancy  may  be,  I  advise  operation  in  all  cases.  So  far 
as  immediate  amendment  is  concerned,  there  is  httle  to 
choose  between  the  mahgnant  and  the  benign  cases.  In 
both  the  patient  begins  to  improve,  the  jaundice  falls 
away  slowly,  sometimes  very  slowly,  and  weight  is  soon 
gained.  The  operation  performed  consists  in  joining  the 
gall-bladder  to  the  intestine,  to  the  duodenum  if  easily 
available  (it  may  be  quite  inaccessible,  lying  high  and 
remote,  when  the  liver  is  enlarged  and  the  gall-bladder 
over-full),  or  to  the  stomach.  It  may  be  feared  that  when 
all  the  bile  passes  directly  into  the  stomach,  nausea,  vomit- 
ing of  bile,  or  loss  of  appetite  results.  Such  fears  are 
groundless.  I  have  joined  the  gall-bladder  to  the  stomach 
in  more  than  20  patients  who  have  survived  a  year  or  more, 
and  there  is  no  suspicion  of  any  special  discomfort  attach- 
ing to  the  operation.  I  have  patients  Kving  still  upon 
whom  I  operated  four,  six,  and  seven  years  ago  in  the 
confident  belief  that  they  suffered  from  carcinoma  and 
would  shortly  be  dead.  It  is  impossible  for  the  most 
astute  chnician  or  the  most  subtle  pathologist  to  discover 
by  physical  signs,  from  the  anamnesis  or  from  the  chem- 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  191 

ical  examination  of  urine  and  faeces,  whether  a  simple  or 
cancerous  disease  is  present.  He  may  shrewdly  guess, 
but  a  guess  is  a  poor  peg  on  which  to  hang  a  man's  Kfe. 
All  cases  of  obstructive  jaundice  should  be  operated  upon; 
the  mortality  of  cholecystenterostomy  now  is  trifling  if  we 
take  into  account  the  severity  of  the  disease  and  the  out- 
look. Apart  altogether  from  the  prolongation  or  saving 
of  Ufe,  almost  every  patient  will  declare  that  the  rehef 
from  the  maddening  torture  of  itching  is  worth  every  sac- 
rifice. 

Acute  pancreatitis,  so  accurately  described  by  Fitz, 
remained  for  long  a  desperate  and  often  lethal  disorder. 
The  onset  of  the  symptoms  was  so  abrupt,  their  course  so 
rapid,  and  the  fatal  event  so  precipitate  that  for  many 
years  surgeons  were  quite  unable  to  realise  the  moment 
for  swift  intervention.  When  operation  was  undertaken 
it  was  generally  upon  the  mistaken  diagnosis  of  perforating 
ulcer  of  the  stomach  or  duodenum.  And  it  was  not  until 
Ramsey,  in  1902,  showed  that  the  chief  surgical  indication 
here,  as  in  the  case  of  a  phlegmon  in  the  extr^nities, 
consisted  in  the  relief  of  tension  that  success  began  to 
attend  the  surgeon's  efforts.  Now  it  is  a  matter  of  very 
little  difficulty  to  make  an  accurate  and  timely  diagnosis 
of  acute  pancreatitis,  and  the  recovery  of  the  patient  can 
generally  be  assured.  A  tribute  here  may  fittingly  be  paid 
to  the  work  of  Simon  Flexner  and  Opie,  who  showed  how 
apt  an  intense  inflammation  of  the  gland  is  to  follow  upon 
the  infection  of  its  duct  by  bile,  by  chemical  irritants,  or 
by  infective  agents.  Acute  pancreatitis  is  not  seldom 
associated  with  cholelithiasis,  bile  which  is  obnoxious  to 
the  gland  passing  from  the  common  duct  to  the  canal  of 
Wirsung  when  the  orifice  of  the  ampulla  is  blocked  by  a 
tiny  stone. 


192  ESSAYS  ON  SURGICAL  SUBJECTS 

Other  diseases  of  the  pancreas,  cysts  and  calcuH,  have 
lent  themselves  also  to  accurate  diagnosis  and  successful 
treatment  by  the  surgeon.  One  of  the  very  ablest  and 
most  original  papers  contributed  to  the  literature  of  sur- 
gery in  my  time  appeared  in  the  British  Medical  Journal 
in  1892  (vol.  ii,  p.  1051).  It  was  written  by  the  great 
surgeon  and  my  very  good  friend,  who  preceded  me  in  the 
delivery  of  this  annual  address,  the  late  Jordan  Lloyd. 
He  pointed  out  that,  contrary  to  the  generally  received 
opinion,  the  fluid  tumours  appearing  in  the  epigastrium 
after  the  receipt  of  an  injury  were  not  veritable  cysts  of  the 
pancreas,  but  accumulations  of  fluid  in  the  lesser  sac  of  the 
peritoneum  which  had  closed  at  the  foramen  of  Winslow. 
Calculi  are  rarely  found  in  the  pancreatic  ducts.  Their 
presence  has  been  recognised,  and  in  a  few  cases  the  stones 
have  been  successfully  removed,  since  the  inauguration  of 
surgical  treatment  by  Pearce  Gould  in  1896. 

The  Source  of  Infection  in  the  Abdomen 

Among  the  most  interesting  and  possibly  one  of  the 
rich  gifts  of  surgery  to  medicine  is  the  hypothesis  that 
intestinal  stasis,  with  the  associated  condition  of  absorp- 
tion of  toxins,  is  responsible  for  many  of  the  diseases  which 
attack  not  only  the  abdominal  viscera,  but  even  also  parts 
remote  therefrom.  Perhaps  no  subject  in  medicine  to-day 
has  received  more  discussion,  has  been  more  bitterly 
assailed,  more  often  attacked  by  derision  rather  than  by 
argument,  and  more  cheerfully  supported  than  this.  Its 
author,  Arbuthnot  Lane,  is  a  man  whose  mind  moves 
easily  along  new  paths.  Such  a  pioneer  has  often  reached 
his  destiny  before  other  tardy  travellers  have  set  out  upon 
the  way.  The  pioneer  in  all  branches  of  knowledge  rarely 
himself  reaches  the  truth — he  is  more  apt  to  overreach,  or 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  193 

to  be  content  to  guess  the  road  that  Hes  ahead  without 
beating  it  down  with  his  own  foot  tread. 

In  contemporary  surgical  history  many  observers,  as  I 
have  pointed  out,  have  had  their  minds  attracted  to  a  firm 
behef  in  one  thing — namely,  that  many  of  the  diseases  for 
which  surgery  is  called  upon  to  deal  are  not  primary  dis- 
orders, but  are  secondary;  that  they  depend  for  their  exist- 
ence and  extended  development  upon  some  common  cause; 
and  that  this  common  excitant  is  an  infection  which  ex- 
presses itself  now  in  one  way,  now  in  another.  The  con- 
ditions I  have  already  mentioned — ulcer  of  the  stomach  or 
duodenum  and  choleHthiasis — are,  in  the  behef  of  all  of  us 
who  do  much  work  for  their  relief,  really  dependent  upon 
an  infection.  For  my  own  part  I  look  upon  the  appendix 
as  the  most  potent  and  the  most  frequent  cause  of  offence. 
Arbuthnot  Lane  takes  a  wider  view.  He  beHeves  that 
the  intestine  itself  is  the  factory  in  which  the  poisons  are 
produced,  which  cause,  or  make  more  easily  possible,  not 
only  the  various  conditions  I  have  named,  but  also  such 
diverse  and  distant  conditions  as  "rheumatoid  arthritis," 
tuberculous  disease  of  bones  and  joints,  diseases  of  the 
breast,  cystic  and  malignant,  of  the  thyroid  gland,  and 
many  other  conditions.  At  first  it  was  supposed  that 
the  large  intestine  was  the  malefactor,  and  some  slender 
support  was  possibly  derived  for  the  hypothesis  from  the 
work  of  Metchnikoff  and  others.  More  recently  the  de- 
layed drainage  of  the  small  intestine  has  been  held  more 
blameworthy.  Various  bands  and  kinks  have  been  de- 
scribed in  different  parts  of  the  alimentary  canal,  and 
these  have  been  held  responsible  for  the  obstruction, 
behind  which  dilatation  and  stagnation  occur.  Con- 
troversy has  raged  around  the  question  as  to  whether 
these  veils  and  kinks  were  developmental  in'origin,  inflam- 

13 


i94  ESSAYS  ON  SURGICAL  SUBJECTS 

matx)ry,  or  evolutionary;  and  very  often  the  opinions  of  a 
writer  are  formed  exclusively  upon,  or  prejudiced  by,  the 
one  out  of  many  possible  methods  of  examination  to  which 
he  has  devoted  exclusive  attention.    The  terminal  ileal 
adhesion,  for  example,  which  is  held  by  many  to  be  the 
most  powerful  of  all  for  evil,  clearly  owns  at  least  two  en- 
tirely different  origins.    The  most  common  form  of  it,  in 
my  view,  is  that  which  depends  upon  inflanunation  of  the 
appendix.     But  it  is  interesting  to  recall  that  in  my  book 
on  "Retroperitoneal  Hernia,"  pubUshed  14  years  ago,  I 
point  out  that  the  "physiological  fusion"  of  Toldt  occurs 
to  excess  in  two  parts  of  the  small  intestine,  with  the  result 
that  there  occurs  "an  adhesion  of  the  upper  few  inches  of 
the  jejunum,  or  the  lower  few  inches  of  the  ileum  to  the 
posterior  abdominal  wall."    I  point  out  there,  moreover, 
a  possibiUty  which  is  constantly  overlooked,  that  this 
physiological  agglutination  is  not  a  process  which  ends 
abruptly  at  birth,  but  that  it  continues  afterwards;  it  is 
possible,  indeed  probable,  that  it  gradually  advances  dur- 
ing adult  life.    So  far  as  the  large  intestine  is  concerned, 
my  own  experience  points  to  the  splenic  flexure  as  the 
part  where  an  arrest  in  the  flow  of  contents  is  most  prone 
to  occur.    Whether  this  is  due  to  an  exaggeration  of  the 
normal  ligamentous  attachments  of  the  flexure,  to  its  ex- 
treme fixity,  or  to  the  dragging  effects  of  an  overweighted 
and  powerless  transverse  colon  I  cannot  say.     But  there 
can  be  no  doubt  that  obstruction  of  the  most  acute,  as  of 
the  most  chronic,  kind  may  be  solely  dependent  upon 
"kinking"  of  the  large  bowel  at  its  splenic  flexure,  sur- 
rounded and  held  firm  by  membranous  adhesions. 

But  these  points,  after  all,  are  only  incidental.  The 
main  question  is  concerned  not  with  the  exact  means  by 
which  effects  are  produced,  but  rather  with  the  existence 


THE  GIFTS  OF  SURGERY  TO  MEDICINE  195 

of  the  alleged  eflFects.  The  fervid  apostles  of  the  new  creed 
are  a  little  prone  to  bewilder  us  with  reasons  for  their  im- 
mature observations.  This  is  only  to  darken  knowledge 
and  to  encumber  their  religion  with  dogma.  We  need 
not  yet  be  greatly  exercised  over  the  terms  of  an  explana- 
tion of  how  these  effects  come  about,  for  in  medicine  ex- 
planation often  lags  far  behind  experience.  The  most  ex- 
emplary instance  of  the  effects  of  alimentary  toxaemia  oc- 
curs, perhaps,  in  the  condition  which  may  best  be  de- 
scribed as  Lane's  disease.  The  miserable  chronic  dys- 
peptic with  saUow  skin,  dirty  tongue,  flaccid  belly,  offen- 
sive breath,  dusky  lips  and  nails,  cold  extremities,  and 
constipation  that  is  with  some  difficulty  overcome,  is 
restored  to  health  with  incredible  rapidity  when  a  short 
circuit  is  made  between  the  ileum  and  the  pelvic  colon. 
The  claims  that  Lane  makes  in  respect  of  such  patients 
must  indubitably  be  admitted.  I  have  never  in  these 
cases,  nor,  indeed,  in  any  of  "alimentary  toxaemia,"  found 
it  necessary  to  consider  the  question  of  a  removal  of  the 
entire  colon.  As  to  the  further  claims  which  are  made,  I 
have  not  yet  arrived  at  the  point  where  I  can  admit 
them,  but  the  hypothesis  charms  by  its  simphcity,  and 
attracts  by  its  magnitude,  and  I  am  travelling  hopefuUy. 

The  Succour  of  the  Individual  and  the  Service  of 

THE  Cause 

Medicine  in  its  quest  of  knowledge  may  rightly  levy  a 
tribute  from  every  other  science  with  which  it  comes  into 
contact.  Its  doctrines  and  its  practise  are  tested,  may 
receive  support,  or  be  refuted,  by  work  accomplished  in 
other  fields.  Surgery  in  recent  years  has  proved  a 
powerful  helpmeet  not  only  in  the  elucidation  of  those 
problems  of  internal  medicine  to  which  I  have  briefly 


i96  ESSAYS  ON  SURGICAL  SUBJECTS 

referred,  but  also  by  reason  of  the  light  it  has  brought  to 
bear  upon  the  functions  of  many  of  the  organs  in  the 
body.  The  experimental  method,  as  a  mode  of  enquiry,  is 
not  excelled  in  value  by  any  other,  and  no  experiments, 
I  hold,  can  claim  an  equal  rank  with  those  which  are  a 
part  of  almost  all  surgical  procedures.  The  chief  glory  of 
the  surgeon  comes  from  the  dedication  of  his  powers  to 
the  service  of  an  individual;  but  there  is  a  cause  also  to 
be  served.  In  every  operation  something  may  be  learnt, 
not  only  of  those  disorders  which  call  urgently  for  rehef, 
but  of  other  associated,  or  it  may  be  separate,  conditions 
which  chance  at  the  same  moment  to  be  present.  The 
researches  so  carried  out  upon  a  human  patient  are  per- 
formed with  a  sterner  sense  of  responsibihty  and  with  a 
graver  ritual,  and  are  impressed  by  more  relevant  influ- 
ences than  attach  to  any  other  form  of  enquiry.  Their 
results  are  accordingly  of  far  higher  value.  Chnical  re- 
search, when  sedulously  conducted  and  illuminated  by  the 
disclosures  made  upon  the  operation  table,  affords  the 
most  accurate  of  all  methods  of  investigation  into  the  dis- 
eases by  which  man  is  attacked.  The  succour  of  an  indi- 
vidual should  mean  also  the  taking  of  a  step  forward  in 
the  solution  or  the  better  understanding  of  the  manifold 
and  perplexing  problems  of  disease. 


THE  SURGERY  OF  THE  CHEST  IN  RELATION 
TO  RETAINED  PROJECTILES^ 

What  is  the  fate  of  patients  who  have  received  wounds 
of  the  chest,  and  who  harbour  a  projectile  within  the 
thoracic  cavity?  There  are  doubtless  many  hundreds,  it 
has  even  been  asserted  that  there  are  thousands,  of  men 
now  in  England  in  whose  lungs  a  projectile  is  retained. 
At  the  present  time  the  evidence  as  to  the  discomforts  or 
dangers  to  which  they  are  prone  is  conflicting.  It  is  con- 
flicting because  it  is  incomplete.  On  the  one  hand  we 
hear  that  some  few  men,  the  bearers  of  a  foreign  body  that 
is  lodged  in  the  lung  or  in  the  mediastinum,  suffer  very 
little;  are  almost  forgetful  of  the  fact  that  thefy  have  been 
wounded;  and  continue  their  civil  work,  sometimes  per- 
haps very  arduous,  without  suffering  any  disabihty  which 
might  lessen  their  value  in  the  labour  market.  On  the 
other  hand  we  find  that  pensioners  come,  in  smaU  numbers 
it  is  true,  to  the  civil  hospitals,  making  complaints  of  the 
distress  they  experience,  and  asking  for  the  removal  of  the 
projectfle  which  they  beUeve  to  be  the  cause  of  their  suf- 
fering. In  these  latter  cases  it  is  neither  the  physical 
properties  of  the  retained  projectile  nor  the  presence  of 
infection  around  it  which  are  alone  to  blame.  For,  of  aU 
the  forms  of  projectile,  a  shrapnell  baU  or  a  rifle  buUet 
might  be  supposed  to  be  the  least  harmful.  Their  sur- 
faces are  smooth,  and  except  at  the  point  of  a  rifle  buUet 
no  injury  is  Hkely  to  be  causefd  by  the  chafing  of  the  pro- 
jectile against  the  tissues  on  movement.  Yet  patients 
with  these  forms  of  foreign  body  seem  to  complain  as  much 
as  do  those  in  whose  chests  a  sharp,  jagged  piece  of  metal 

1  Reprinted  from  The  BrUish  Journal  of  Surgery,  Vol.  YII,  No.  28,  1920. 
""■  197 


198  ESSAYS  ON  SURGICAL  SUBJECTS 

is  lodged.  Nor  is  the  degree  of  infection  alone  responsible, 
as  is  seen  from  the  record  of  a  case  where  a  sterile  rifle 
bullet  was  found  embedded  in  lung  tissue.  Except  for  the 
greater  Ukelihood  of  post-operative  troubles,  such  as  sup- 
puration of  the  wound,  or  empyema,  there  does  not  appear 
to  be  any  conspicuous  clinical  distinction  to  be  made  be- 
tween those  cases  in  which  the  foreign  bodies  are  infected 
and  those  in  which  the  projectile  is  sterile.  And  it  is  in- 
teresting to  note  that,  although  the  lung  is  admittedly  as 
capable  of  defending  itself  against  microbic  attack  as  any 
part  of  the  body,  an  active  infection  may  be  found  upon  a 
projectile  removed  after  three  years'  lodgement  in  the 
parenchyma. 

Nor  does  the  position  of  the  foreign  body  in  the  lung 
afford  any  constant  clue  as  to  the  cause  of  the  symptoms 
of  which  complaint  is  made.  It  is  true  that  if  the  foreign 
body  Kes  in,  or  in  contact  with,  the  heart,  the  anxiety  of 
the  patient  as  to  his  future  is  increased.  But  whether  a 
missile  is  lodged  in  one  part  of  the  lung  or  another  does  not 
seem  to  be  of  importance,  so  far  as  the  existence  or  the 
severity  of  the  chief  symptoms  is  concerned. 

The  frequency,  therefore,  with  which  symptoms  are 
present  in  the  case  of  those  harbouring  projectiles  in  the 
chest  is  uncertain.  So  far  as  an  enquiry  is  concerned  which 
cannot  pretend  to  statistical  accuracy,  it  appears  to  be 
certain  that  the  great  majority  of  men  make  some  com- 
plaint of  subjective  phenomena.  So  long  ago  as  1916, 
Denechau,  in  an  enquiry  into  the  condition  of  fifty  patients 
whose  woimds  dated  back  many  months,  ehcited  a  history 
in  every  case  of  subjective  disorders.  In  the  times  of 
active  warfare  we  were  all  naturally  and  properly  suspi- 
cious of  purely  subjective  complaints.  Scepticism  and 
incredulity  were  our  defence  against  the  blandishments 


THE  SURGERY  OF  THE  CHEST  199 

and  the  special  pleading  of  many  an  "old  soldier."    But 
the  similarity  of  the  symptoms  in  a  long  series  of  cases, 
where  collusion  is  impossible,  makes  it  unlikely  that  ma- 
lingering alone  is  responsible.    Exaggeration  there  may  be, 
but  similarity  or  identity  of  invention  in  many  patients, 
at  long  intervals  of  time,  and  widely  separated  geographic- 
ally, is  unlikely.     And  it  was  not  long,  in  my  experience, 
before  patients  who  had  been  discharged  from  the  army 
returned  to  hospital  still  complaining  of  their  symptoms, 
and  were  willing,  even  eager,  to  submit  to  operation  for 
their  reHef.     So  that  if  we  discount  fully  the  element  of 
exaggeration,  we  are  still  confronted  by  a  considerable 
body  of  evidence  which  goes  to  show  that  a  projectile  re- 
tained in  the  chest  is  a  source  of  discomfort,  variable  in 
intensity,  duration,  and  frequency,  and  of  serious  eoixiety. 
In  my  early  experience  I  refrained  from  operating  upion 
many  patients,  partly  from  ignorance  of  several  matters 
concerned  with  intrathoracic  surgery,  and  partly  in  the 
hope  that  delay  in  operating  would  allow  of  the  firm  en- 
capsulation of  the  projectile,  and  the  gradual  recovery  of 
the  lung  to  a  normal  condition,  or  to  a  condition  so  nearly 
approaching  the  normal  as  to  encourage  the  patient  to  re- 
turn happily  to  full  work.    My  advice  to  patients  not  to 
submit  to  operation  was  not  always  well  received;  and 
often  I  was  urged  to  consider  the  removal  of  the  projectile, 
as  the  patient  was  prepared  to  take  the  risk,  though  I  had 
spoken  of  it  in  terms  which  now  I  realize  were  unduly 
grave. 

In  endeavouring  to  decide  upon  the  principles  which 
should  govern  us  in  the  advice  we  give  as  to  the  removal 
of  projectiles  from  the  chest,  we  have  to  consider,  on  the 
one  hand,  the  pathological  conditions  caused  by  the  en- 
trance of  the  projectile,  the  severity  of  the  symptoms 


200  ESSAYS  ON  SURGICAL  SUBJECTS 

aroused,  and  the  prospects  of  increasing  or  diminishing 
discomfort,  disabihty,  or  danger  from  the  continued  lodge- 
ment of  the  foreign  body  or  from  the  changes  aroused  at 
its  rude  entrance;  and,  on  the  other  hand,  the  severity  of 
the  operation  necessary  for  the  removal  of  the  missile,  the 
mortahty,  the  post-operative  discomforts,  and  the  results 
as  expressed  in  the  altered  conditions  in  the  chest,  and  in 
the  consecutive  changes  in  those  symptoms  for  which  the 
patient  first  sought  rehef. 

Among  the  projectiles  found  in  the  chest  cavity,  frag- 
ments of  shell  are  the  commonest.  They  are  usually  of 
small  size,  rarely  more  than  an  inch  in  length ;  they  have 
rough  and  pitted  surfaces,  jagged  edges,  and  sharp  points. 
In  a  small  proportion  of  cases  fragments  of  clothing  are 
carried  in  with  the  metal,  and  are  found  lying  with  it  in  the 
chest.  In  most  instances  there  is  only  one  piece  of  metal. 
Machine-gun  or  rifle  bullets  are  found,  and  shrapnel  balls. 
On  one  occasion  in  a  series  of  cases  a  shrapnel  ball  was 
loose  in  the  pleural  cavity,  in  which  it  could  be  seen  to  roll 
about  freely.  It  is  very  rare  to  find  a  large  piece  of  metal 
in  the  chest ;  the  probability  is  that  all  patients  into  whose 
chests  such  a  foreign  body  penetrates,  die  as  the  early  re- 
sult of  their  injury. 

I  propose  to  consider  the  subject  in  the  following  order: 

A.  Pathological  changes  caused  by  projectiles  within 

the  chest. 

B.  Symptoms  to  which  they  give  rise. 

C.  Operations  for  the  removal  of  projectiles. — General 

principles.  Indications  for  operation.  Opera- 
tions: (1)  Method  of  Petit  de  la  Villeon;  (2) 
Marion's  method;  (3)  Duval's  method;  (4) 
Operations  upon  the  root  of  the  lung;  (5)  Op- 
erations upon  the  mediastinum. 


THE  SURGERY  OF  THE  CHEST  201 


D,  After-history,  and  results  of  operations. 

E.  List  of  cases  treated  by  operation. 

A.  Pathological    Changes  Caused  by  Projectiles 
Within  the  Chest 

1.  Wound  of  Entry. — As  a  rule,  the  wound  made  by  the 
projectile  on  entering  the  chest  has  healed.  In  the  major- 
ity of  the  cases  I  have  seen,  the  wound  is  in  the  chest  wall 
(it  may  be  in  the  neck  or  in  the  abdomen),  sometimes  on 
the  side  where  the  projectile  has  lodged,  sometimes  on  the 
other  side,  a  portion  of  the  opposite  pleural  cavity  and  the 
mediastinum  having  been  traversed  before  the  missile 
comes  to  rest.  It  is  very  remarkable  to  find  that  the  medi- 
astinum with  all  its  contents  may  be  pierced  by  a  bullet 
or  a  fragment  of  shell,  and  yet  the  parts  apparently  suffer 
not  the  shghtest  injury.  The  supple  and  elastic  vessels 
seem  to  yield  place  to  the  swiftly-moving  metal ;  they  cer- 
tainly escape  damage  in  a  manner  that  sometimes  appears 
incredible.  In  a  few  instances  the  bullet  has  passed 
through  the  arm  into  the  chest;  and  in  one  case  of  mine 
some  fragments  of  the  humerus  had  been  carried  into  the 
lung.  The  rib  at  the  point  of  entry  may  be  fractured, 
and  minute  fragments  and  splinters  of  the  bone  be  swept 
inwards  to  the  pleural  cavity  and  the  lung;  a  similar  lesion 
may  occur  in  the  scapula  or  the  sternum.  It  is  the  rule  to 
find  only  one  wound  of  entry,  but,  as  in  other  parts  of  the 
body,  the  superficial  lesions  may  be  multiple,  many  frag- 
ments of  sphntered  metal  entering  the  chest  wall,  one  or 
more  of  them  passing  through  the  parietes  to  lodge  in  the 
lung  tissue. 

The  same  conditions  in  respect  of  the  missiles  and  their 
effects  upon  the  soft  parts  are  found  in  the  chest  as  in  the 
tissues  of  the  limbs.    The  damage  inflicted  depends  upon 


202  ESSAYS  ON  SURGICAL  SUBJECTS 

the  size  and  shape  of  the  projectile,  its  physical  properties 
in  respect  of  roughness  and  sharp  edges,  and  its  velocity. 
A  rifle  bullet  discharged  at  a  distance  of  1500  yards,  when 
its  flight  has  become  steady,  may  pass  through  the  chest, 
cleaving  its  way,  and  leave  behind  very  Httle  evidence  of 
trauma.  A  smaU  fragment  of  coarse  metal  of  ugly  shape 
and  lower  velocity  may  bruise  and  tear  and  crush  any- 
thing that  lies  in  its  path. 

Wounds  of  the  chest  are  often  found  in  association 
with  wounds  elsewhere:  in  the  abdomen,  extremities,  or 
head.  Not  only  is  the  immediate  problem  of  appropriate 
treatment  affected  thereby,  but  also  the  duration  of  con- 
valescence and  the  quahty  of  the  ultimate  recovery. 

2.  The  Path  of  the  Projectile. — So  far  as  the  soft  parts 
are  concerned,  the  lesions  at  once  produced,  and  the  con- 
ditions remaining  after  healing,  are,  as  I  have  said,  not 
different  from  those  seen  elsewhere.  In  the  lung  itself 
the  course  taken  by  a  piece  of  metal  can  often  be  felt  as  a 
thick  cord  or  strand  when  the  lung  is  grasped  in  the  hand. 
It  is  interesting  that,  in  most  instances,  the  foreign  body  is 
found  near  the  surface  of  the  lung;  rarely  in  the  middle  of 
a  lobe.  It  would  seem  that  the  central  lung  tissue  itseff 
offers  very  httle  resistance  to  the  passage  of  a  fragment  of 
metal,  which  is  brought  to  rest  by  the  increased  resistance 
it  meets  at  the  surface  of  a  lobe.  The  projectile  itself  may 
be  found  at  the  very  surface  of  the  lung,  embedded  in  ad- 
hesions of  great  thickness  and  density.  In  some  instances 
it  is  not  easy  to  say  whether  it  has  lain  actuaUy  within  the 
substance  of  the  lung,  or  in  masses  of  lymph  deposited  on 
the  visceral  pleura. 

Two  or  three  times,  in  separating  the  lung  from  the 
chest  waU  as  gently  as  possible,  I  have  felt  the  foreign 
body  drop  into  my  hand.    The  surface  of  the  lung,  when 


THE  SURGERY  OF  THE  CHEST  203 

examined,  merely  showed  a  shallow  pit  with  a  rough  and 
shaggy  wall.  In  other  instances  the  metal  is  frankly  in 
the  Imig  tissue,  which  has  to  be  incised  in  order  to  release 
the  foreign  body.  The  lung  may  then  show  signs  of 
"hepatization,"  being  thick,  hard,  and  red.  Or  in  rare 
instances  the  metal  may  be  surrounded  by  a  very  thick 
yellow  fibrous  capsule,  within  which  are  the  remains  of  a 
small  collection  of  dried  pus. 

In  one  case  of  mine  the  tissue  cut  through  resembled 
exactly  the  structure  and  consistence  of  a  calcareous  mes- 
enteric gland,  and  for  a  moment  I  was  incHned  to  think 
that  the  condition  with  which  I  was  deahng  was  tubercu- 
lous. But  as  I  cut  deeper  into  the  dense  tissues  I  felt  the 
metal  against  the  knife,  and  a  small  fragment  of  shell-cas- 
ing was  released.  Complete  encapsulation  of  any  foreign 
body  is  extremely  rare.  It  is  not  often  that  a  piece  of 
clothing  is  found  with  the  metal;  when  so  found  it  is  dark, 
deeply  blood-stained,  often  offensive,  and  always  infected. 
In  two  cases  bronchiectasis  was  present,  caused,  no  doubt, 
by  the  pressure  of  a  fragment  of  metal  of  rather  large  size 
upon  a  large  bronchus.  In  both  cases  expectoration  be- 
fore operation  was  profuse,  and  sometimes  foetid;  in  both 
there  was  local  collapse  of  the  lung,  and  in  both  the  con- 
dition was  seen  on  a;-ray  examination. 

3.  Condition  of  the  Pleural  Surfaces. — This  varies  with- 
in very  wide  limits.  I  have  often  been  struck  by  the  ap- 
parent discrepancy  between  the  pathological  conditions 
discovered  in  the  chest  at  the  time  of  operation,  and  the 
evidence  of  such  conditions  afforded  by  the  ordinary 
methods  of  chnical  examination.  It  is  evident  that  per- 
cussion and  auscultation,  even  by  the  most  expert  phys- 
ician, reveal  only  the  coarser  defects,  and  do  not  always  dis- 
cover even  them.    What  appear  to  the  surgeon  to  be  gross 


20U  ESSAYS  ON  SURGICAL  SUBJECTS 

changes  may  be  quite  unrecognizable  on  clinical  investi- 
gation. 

Adhesions  of  the  two  pleural  surfaces  are  almost  always 
present.  They  may  be  of  the  slightest  and  flimsiest  text- 
ure, breaking  down  at  the  gentlest  touch,  and  scattered 
thinly  over  a  hmited  area.  They  may  be  of  considerable 
density,  and  restricted  to  the  hue  of  flight  of  the  foreign 
body.  A  thick  anchorage  of  adhesions  is  then  found,  and 
the  rest  of  the  pleura  may  have  few  adhesions  or  none.  In 
other  instances  the  two  pleural  surfaces  may  have  become 
so  intimately  adherent  that  it  is  possible  to  separate  them 
only  by  the  exercise  of  the  greatest  force  short  of  rough- 
ness. Indeed,  in  some  few  instances  I  have  been  quite 
powerless  to  separate  adhesions,  and  have  had  to  divide 
them  with  knife  and  scissors;  even  then  their  severance  has 
been  most  difficult.  In  some  instances  the  lymph  poured 
out  has  become  organized  into  the  densest  and  heaviest 
felt-like  material,  which  I  have  been  able  to  dissect  away 
in  large  sheets,  and  to  keep  as  a  specimen.  Where  ad- 
hesions are  so  very  massive,  they  may  isolate  a  small  or 
large  collection  of  fluid,  old  blood-clots,  desiccated  pus,  or 
serum.  Dense  adhesions  may  be  limited,  only  lying  in 
the  path  of  the  projectile,  as  I  have  just  stated ;  or  they  may 
cover  the  whole  of  one  lobe,  the  other  lobe  or  lobes  being 
free;  or  virtually  the  whole  of  the  pleural  surfaces  may  be 
involved.  The  lobes  of  the  lung  may  adhere  to  each  other. 
The  lung  may  adhere  along  the  inner  side  to  the  medias- 
tinum or  to  the  pericardium.  On  the  left  side,  especially, 
it  may  be  difficult  to  say  whether  a  foreign  body  which 
moves  with  the  heart  is  in  the  edge  of  the  lung,  or  on,  or  in, 
the  pericardium ;  for  the  parts  adhere  strongly  and  are  not 
anatomically  distinguishable  one  from  another;  a  mass  of 
fibrous  tissue  binds  them  all  together.     In  several  in- 


THE  SURGERY  OF  THE  CHEST  205 

stances  I  have  found  very  strong  adhesions  of  the  lung  to 
the  diaphragm,  and  the  costodiapliragmatic  angle  has  been 
filled  with  the  organized  remains  of  old  blood-clot  or  of  a 
pleural  effusion.  The  immobihty  of  the  corresponding 
half  of  the  diaphragm,  as  seen  by  x-ray  examination,  is 
easily  understood  in  such  cases. 

4.  Infectivity  of  Projectiles. — It  was  not  always 
thought  proper  to  examine  the  projectile  bacteriologically; 
this  was  done  only  in  those  cases  where  the  metal  was 
lifted  directly  out  of  its  bed  with  sterile  forceps,  and  held 
while  a  smear  was  taken  from  it.  In  all,  eighteen  projec- 
tiles were  examined.  In  eleven  there  was  infection  by 
Staphylococcus  aureus,  streptococci,  pneumococci,  or  coH- 
form  bacilli.     In  seven  the  foreign  body  was  sterile. 

B.  Symptoms  Present  in  Cases  Where  a  Foreign 
Body  is  Retained  in  the  Chest 

1.  Pain. — This  is  present  in  the  affected  side  of  the 
chest.  It  is  very  variously  described  as  "soreness," 
"pricking,"  "stabbing,"  "burning."  It  is  fairly  constant, 
but  is  increased  when  any  exertion,  work  or  play,  is  under- 
taken. More  than  one  patient  has  told  me  that  he  felt 
then  as  though  the  side  of  the  chest  were  being  "held  in  a 
clutch,"  and  that  the  pain  was  insupportable  and  brought 
with  it  a  sense  of  acute  anxiety  and  distress.  The  amount 
or  the  quahty  of  the  pain  suffered  does  not  often  appear  to 
have  borne  any  very  close  relationship  to  the  size  of  the 
projectile,  to  the  extent  or  position  of  the  wound  or  wounds 
of  entry  or  exit,  to  the  presence  of  operation  wounds  (in- 
dicating that  an  effort  has  been  made  to  deal  with  the  pro- 
jectile, or  with  the  injured  lung),  to  a  former  empyema,  to 
the  restrictions  in  the  movement  of  the  diaphragm  as  dis- 
covered by  x-ray,  or  to  the  observed  physical  signs.    It  is 


206  ESSAYS  ON  SURGICAL  SUBJECTS 

certain  that  the  pain  is  no  worse  in  those  cases  where  very 
extensive  and  extremely  dense  adhesions  are  present.  In 
severed  of  my  cases  the  pleural  cavity  was  quite  obliter- 
ated, and  the  cohesion  of  the  pleural  surfaces  was  with 
the  utmost  difficulty  undone.  Yet  patients  so  afflicted 
made  no  unusual  complaint  of  pain. 

Grey  Turner  has  observed  that  pain  and  tenderness  are 
especially  noticeable  in  cases  where  a  locaHzed  area  of  ad- 
hesions is  found  in  the  track  of  the  missile — ^where,  that  is 
to  say,  a  part  only  of  the  lung  is  firmly  anchored  to  the 
pleura,  the  rest  being  free  to  move.  A  general  diffuse  ad- 
hesion, he  says,  between  the  pleural  surfaces  is  not  at- 
tended with  pain,  and,  indeed,  may  be  a  means  of  prevent- 
ing it.    These  observations  agree  with  my  own. 

In  my  earher  cases  I  was  a  httle  at  a  loss  to  account  for 
the  pain  of  which  so  grievous  complgunts  were  sometimes 
made,  and  I  was  almost  persuaded  that  the  knowledge  of 
the  patient  that  a  projectile  was  retained  in  the  lung,  to- 
gether with  a  possible  reluctance  to  be  considered  fit  for 
duty  in  the  line,  might  be  held  largely  responsible  for  the 
manifold  complaints.  But  this  view  was  soon  found  to  be 
untenable  when  pensioners,  who  were  no  longer  faced  with 
the  possibihties  of  further  service,  who  indeed  had  some- 
thing to  lose  by  being  laid  aside  from  work  more  remuner- 
ative than  ever  before,  came  to  the  hospital  seeking  relief. 
In  them  there  was  no  need  to  estimate  and  to  discount  the 
coefficient  of  exaggeration. 

By  degrees  it  became  certain  that  pain  in  all  such  cases 
was  a  real  thing.  In  a  large  number  of  patients  who  have 
missiles  retained  anywhere  in  the  chest  there  is  a  consider- 
able degree  of  apprehension  as  to  their  future,  a  far  greater 
degree,  in  my  experience,  than  is  found  in  men  who  have 
pieces  of  metal  lodged  elsewhere.    I  know  no  reeison  for 


THE  SURGERY  OF  THE  CHEST  W7 

this,  but  the  fact  is  beyond  doubt.  In  the  years  1915  and 
1916  I  saw  seven  patients  who  did  not  appear  to  me  to  be 
suffering  sufficiently  to  make  it  worth  their  while  to  sub- 
mit to  operation;  all  were  dissatisfied  with  my  advice  to 
have  nothing  done,  and  most  of  them  came  back  finally 
for  operation. 

2.  DyspncBa. — This  varies  greatly  in  different  cases. 
It  may  be  felt  only  on  severe  or  protracted  exertion ;  it  may 
be  sHght  even  then.  Or  it  may  be  an  almost  constant 
symptom,  present  when  the  patient  is  in  repose,  greatly 
augmented  when  he  walks  hurriedly,  and  especially  on 
going  upstairs  or  on  climbing  a  hill  with  an  eager  pedes- 
trian. There  are  times  when  pain  and  dyspnoea  together 
produce  a  crisis  of  exhaustion,  and  the  patient  almost  col- 
lapses in  an  agony  of  distress.  I  have  twice  seen  patients 
in  this  condition  when  walking  near  the  hospital.  The 
dyspnoea  on  repose  and  the  effort  dyspnoea,  in  all  proba- 
bihty,  are  both  due  to  embarrassment  of  the  lung  crippled 
by  adhesions,  or  to  the  massive  remnants  of  an  old  hsemo- 
thorax,  or  to  the  shrinkage  of  the  side  of  the  chest  and  the 
mediastinal  displacement  and  collapse  of  the  lung  which 
follow  an  empyema.  There  is  not  always  a  correspond- 
ence between  the  degree  of  distress  and  the  amount  of 
physical  incapacity  or  deformity  of  the  chest. 

3.  Cough. — This  symptom  is  frequent  as  a  rule,  indeed, 
in  some  degree  constant;  though  there  are  intervals  in 
which  it  may  be  in  abeyance,  especially  if  the  patient  is 
kept  in  bed,  or  is  bedridden  by  another  lesion.  Its  pres- 
ence is  due  not  so  much  to  the  metal  in  the  chest,  as  to 
such  associated  conditions  as  sinuses  leading  down  to  the 
pleural  cavity  or  into  the  lung;  to  infection  around  the 
foreign  body,  causing  local  hepatization  of  the  lung,  or 
abscess;  or  to  bronchiectasis  or  emphysema. 


208  ESSAYS  ON  SURGICAL  SUBJECTS 

When  an  external  sinus  leads  into  the  lung,  its  tempo- 
rary closure  may  coincide  with  a  period  in  which  a  teasing 
cough  is  accompanied  by  the  copious  expectoration  of  pus. 

In  a  few  cases  hsemoptysis  occurs.  It  is  not  often 
severe,  but  may  be  repeated  on  several  occasions.  It  ap- 
pears especially  apt  to  follow  on  severe  exertion.  The 
first  case  in  which  I  saw  it  occurred  in  a  man  wounded  in 
September,  1914;  a  large  fragment  of  shell-casing  was  re- 
tained in  the  lower  lobe  of  the  right  lung.  The  wound 
healed,  and  in  April,  1915,  he  was  returned  as  fit  for  duty. 
He  was  given  bayonet  practice,  and  a  sharp  haemorrhage 
occurred  at  once;  a  like  experience  followed  on  two  occa- 
sions within  a  few  days,  and  he  then  consulted  the  regi- 
mental medical  officer. 

I  have  seen  three  cases  in  which  pain,  dyspnoea,  cough, 
purulent  expectoration,  and  hsemoptysis  have  been  present 
and  have  led  to  a  diagnosis  of  pulmonary  tuberculosis. 
Similar  cases  are  recorded  by  Dehnas  and  Fiolla.  In  one 
of  my  cases  an  x-ray  diagnosis  of  a  piece  of  metal  retained 
in  the  lung  was  made,  and  an  operation  performed.  No 
foreign  body  was  found.  The  patient  was  subsequently 
stated  to  be  suflFering  from  phthisis. 

The  expectoration  is  sometimes  abundant,  frothy, 
purulent,  and  ofiFensive.  It  appears,  as  a  rule,  within  a 
week  or  two  of  the  infliction  of  the  injury,  and  it  is  rarely 
relieved  by  any  treatment  other  than  removal  of  the  for- 
eign body;  after  that  it  disappears  at  once. 

4.  Proneness  to  Chill. — On  making  inquiry  into  the 
clinical  history  of  patients  in  whose  lung  a  foreign  body  is 
retained,  I  have  been  struck  by  their  frequent  reference  to 
attacks  of  "colds"  or  "chills."  In  these  attacks,  which 
last  only  a  few  days,  the  patient  feels  cold,  shivers,  has 
"goose  flesh,"  feels  miserable,  and  keeps  huddled  over  a 


THE  SURGERY  OF  THE  CHEST  209 

fire.  The  dyspnoea  and  cough  are  a  Httle  worse,  slight 
haemoptysis  may  occur,  and  exertion  is  avoided.  The 
temperature  is  raised  for  two  or  perhaps  three  evenings  to 
101°  or  102°.  The  httle  attack  soon  passes  off,  and  the 
patient  feels  himself  again.  These  recurrent  waves  of 
infection — for  that  is  what  they  are — show  that  the  lung  is 
not  always  tolerant  of  the  presence  of  a  septic  foreign 
body. 

5.  Palpitation. — A  number  of  patients  have  complained 
of  severe  palpitation,  and  of  pain  over  the  heart,  as  well  as 
dyspnoea  upon  exertion ;  and  several  of  them  felt  reluctant 
to  he  upon  the  affected  side.  Irregularity  of  the  pulse  has 
never  been  noted,  nor  intermission. 

In  a  very  few  cases  there  have  been  complaints  of  di- 
gestive discomforts,  pain  and  flatulence  after  food,  eructa- 
tion chiefly  due  to  air-swallowing,  and  constipation.  In 
the  worst  of  the  cases  there  were  many  adhesions  of  the 
lung  to  the  diaphragm. 

C.  Operations    for    the    Removal    of    Projectiles 
FROM  the  Chest 

GENERAL  PRINCIPLES   AND   DETAILS 

The  subject  of  thoracic  surgery  is  one  which,  before  the 
war,  had  been  made  difficult  by  the  cumbersome  methods 
employed.  The  fear  of  collapse  of  the  lung  when  pneumo- 
thorax occurred  was  present  in  the  minds  of  most  surgeons, 
and  was  a  powerful  deterrent.  The  dread  of  pneumo- 
thorax was  in  truth  the  great  inhibitory  influence  hinder- 
ing the  development  of  thoracic  surgery.  In  the  behef 
that  it  was  necessary  to  prevent  this,  Sauerbruch  and 
others  in  Germany,  and  WiUy  Meyer  in  New  York,  had 
devised  and  employed  positive-pressure  apparatus  for 


210  ESSAYS  ON  SURGICAL  SUBJECTS 

anaesthesia,  and  negative-pressure  chambers  in  which  the 
trunk  of  the  patient  and  the  operation  team  were  sta- 
tioned during  the  whole  of  the  procedures  conducted  upon 
an  opened  thorax. 

There  was,  however,  abundant  evidence  to  show  that 
the  fear  of  pneumothorax  was  greatly  exaggerated.  For 
many  years  past  I  have  been  accustomed,  in  performing 
operations  upon  the  kidney  for  stone  or  for  removal  of  that 
organ,  to  begin  by  excising  the  last  rib  in  order  to  obtain 
more  room,  and  in  order  also  to  prevent  undue  dragging 
upon  the  pedicle  of  the  kidney.  In,  possibly,  a  dozen  of 
such  cases  I  have  wounded  the  pleura  and  have  heard  the 
air  enter  freely  into  the  chest.  No  disabihty  or  distress 
followed,  and  I  looked  upon  the  misadventure  as  rather  a 
flaw  in  the  artistry  of  the  operation  than  a  matter  of  sur- 
gical importance,  a  rebuke  to  my  skill  rather  than  a  risk 
to  the  patient.  Similarly,  in  operating  upon  recurrent 
local  growths  in  cases  of  carcinoma  of  the  breast,  I  have  re- 
moved portions  of  the  chest  wall  and,  by  mishap  or  dehb- 
erate  intention,  have  wounded  the  pleura.  Again  no 
harm  followed.  It  is  well  known  that  Bazy,  of  Paris,  had 
spoken  of  the  safety  of  open  operations  on  the  chest  for 
years  before  the  war;  and  had  derided  the  supposed  diffi- 
culties or  dangers  following  the  free  entry  of  air  into  the 
pleura,  provided  always  that  there  was  no  myocardial 
disease. 

All  these  experiences  and  opinions  have  been  abun- 
dantly confirmed  by  the  knowledge  we  now  have  of  chest 
airgery  in  the  late  stages  of  gunshot  wounds.  The  entry 
of  air  into  the  cavity  of  the  pleura  has  produced  one  effect 
only,  a  temporary  quiescence  or  cessation  of  the  respira- 
tions. Before  opening  the  pleura  we  have  taken  pains  to 
obtain  a  deep  anaesthesia.    Air  is  allowed  to  enter  the 


THE  SURGERY  OF  THE  CHEST  2il 

pleura  slowly  through  an  incision  which,  smgdl  at  first,  is 
subsequently  freely  enlarged,  so  as  to  allow  of  the  easy 
entry  of  the  hand  into  the  chest  cavity.  The  lung  at  once 
collapses,  but  the  degree  of  collapse  is,  as  a  rule,  shght 
compared  with  our  expectations.  It  is  not  the  degree  of 
collapse  seen  in  the  post-mortem  room.  Such  as  it  is,  it  is 
entirely  to  the  advantage  of  the  surgeon:  it  allows  his 
manipulation  to  be  more  freely  conducted  within  the 
chest;  it  enables  him  to  reach  all  parts  of  the  lung  more 
easily ;  and  it  permits  of  the  withdrawal  of  every  part  of 
the  lung  except  the  hilum  from  its  ordinary  position  up  to 
the  anterior  wound,  and  even  outside  the  chest  wall.  I 
can  imagine  only  one  serious  risk  in  the  making  of  an  open 
pneumothorax,  and  that  is  the  wounding  of  the  opposite 
pleura  and  the  production  of  a  double  pneumothorax. 
That  ha-s  never  occurred  in  any  of  my  cases,  and  in  opera- 
tions upon  the  lung  is,  I  suppose,  an  impossible  catas- 
trophe. 

If,  however,  the  oesophagus  were  being  in  part  excised, 
the  danger  would  be  a  real  one  and  need  to  be  kept  in 
mind.  Emboldened  by  my  experience  in  these  cases  of 
gunshot  wound  of  the  chest,  and  on  the  urgent  demand  of  a 
patient,  I  recently  excised  a  growth  including  3  in.  of  the 
cesophagus.  The  growth  lay  below  the  arch  of  the  aorta, 
to  which,  and  to  the  posterior  surface  of  the  left  auricle,  it 
was  firmly  adherent.  I  excised  the  7th  left  rib  and  divided 
the  6th,  5th,  4th,  and  3rd  ribs  posteriorly,  and,  introducing 
Balfour's  abdominal  retractor,  spread  the  ribs  apart  very 
widely.  I  laid  the  pleural  cavity  open  freely  and  obtained 
a  wonderful  view  of  the  heart,  aorta,  great  vessels  arising 
from  it,  trachea,  oesophagus,  and  lung.  The  actual  opera- 
tion for  removal  was  then  made  very  easy ;  but  remember- 
ing that  the  relations  of  the  oesophagus  in  that  region  are 


2i2  ESSAYS  ON  SURGICAL  SUBJECTS 

more  intimate  with  the  right  plem'a  than  with  the  left, 
the  most  scrupulous  care  was  taken  to  avoid  any  opening 
of  the  opposite  pleural  cavity. 

The  Separation  of  the  Pleural  Adhesions. — The  num- 
ber, density,  and  strength  of  the  adhesions  found  in  the 
pleural  cavity  vary  within  the  widest  limits.  They  may 
be  few,  thin,  and  Kght,  separating  at  the  gentle  touch  of 
the  finger;  or  they  may  be  of  the  utmost  density.  I  have 
several  times  had  to  dissect  off  from  the  surface  of  the  lung 
thick  masses  of  hnnph,  as  sohd  as  the  felt  of  which  a  flat- 
foot  pad  is  made.  In  such  a  case  it  is  interesting  to  see  the 
lung  expanding  httle  by  httle  as  it  is  freed  from  the  dense 
adhesion  which  has  clearly  been  compressing  it. 

In  my  earHer  cases  I  felt  that  the  indication  for  opera- 
tion was  the  presence  of  the  foreign  body  in  the  lung,  and 
that  the  removal  of  that  foreign  body  was  the  sole  purpose 
of  the  operation  to  be  performed.  By  degrees  I  came  to 
beheve  that  the  removal  of  the  projectile  was  only  a  part, 
and  perhaps  not  always  the  most  important  part,  of  the 
operation.  The  adhesions  encountered  were  so  consid- 
erable in  many  instances  that  I  became  persuaded  their 
presence  alone  would  account  for  most  of  the  disabihties 
of  which  the  patient  complained,  and  that  their  separation 
or  removal  would  alone  give  relief  to  all  distress.  But 
realizing  the  frequency  of  infection  present  on  the  foreign 
body  and  the  occasional  presence  of  fragments  of  clothing 
which  were  always  very  oflFensive,  I  concluded  that  the 
purpose  of  the  operation  was  a  dual  one,  and  that  there 
was  perhaps  Httle  to  choose  between  the  relative  impor- 
tance of  the  two  intentions. 

The  separation  of  dense  adhesions  following  perhaps 
upon  a  hsemothorax  or  upon  an  empyema  is  by  no  means 
free  from  serious  consequences,  especially  if  the  foreign 


THE  SURGERY  OF  THE  CHEST  213 

body,  which  at  last  is  reached  and  removed,  is  infected. 
In  five  of  my  cases  empyema  followed  such  a  procedure: 
in  all  the  foreign  body  was  infected,  in  all  there  was 
haemorrhage  into  the  pleural  cavity  after  the  operation, 
and  aspiration  of  this  was  in  the  first  place  necessary. 
The  lesson  to  be  learnt  from  this  experience  is  that,  in  all 
cases  requiring  the  removal  of  dense  adhesions,  the  great- 
est care  should  be  taken  to  secure  perfect  haemostasis  be- 
fore the  chest  is  closed.  We  have  only  a  shght  experience 
of  draining  such  cases  for  one  or  two  days,  but  such  as  it 
is  it  suggests  that,  where  oozing  cannot  be  completely 
checked  at  the  time  of  operation,  drainage  gives  safety  and 
comfort.  The  continuance  of  the  tube  for  longer  than, 
say,  thirty-six  hours  is  probably  harmful.  Our  general 
practice  has  been  firmly  and  continually  opposed  to  drain- 
age wherever  possible. 

The  dual  intention  of  the  operation  is  shown  also  by 
a  consideration  of  those  cases  in  which  the  projectile  has 
passed  completely  through  the  thorax,  or  has  passed 
through  the  pleural  cavity  and  Hes  embedded  in  the  chest 
wall.  In  such  cases  a  high  degree  of  respiratory  embarras- 
ment,  due  to  pleural  adhesions  the  result  of  an  old  haemo- 
thorax,  may  be  present.  The  opening  of  the  chest  cavity 
to  free  the  lung  from  the  thick  membranes  which  cripple 
its  action  is  then  certainly  desirable,  though  no  foreign 
body  require  to  be  removed. 

Anaesthesia. — The  question  of  the  anaesthetic  to  be 
used  required,  of  course,  very  anxious  consideration.  We 
considered  first  the  possibility  of  performing  all  the  opera- 
tions under  local  infiltrative  anaesthesia,  or  under  the  para- 
vertebral regional  anaesthesia  which  I  have  seen  used  so 
successfully  by  Pauchet,  of  Amiens.  Chloroform  here, 
as  elsewhere,  I  refused  to  sanction.    The  obvious  dangers 


2f4  ESSAYS  ON  SURGICAL  SUBJECTS 

are  great,  and  its  remote  dangers  in  all  cases  not  yet  suffi- 
ciently realized.  For  years  I  have  abandoned  its  use,  and 
I  saw  no  reason  to  try  it  in  cases  of  this  kind. 

Ether  has  proved  so  satisfactory  in  all  my  work  that  I 
determined,  if  possible,  to  retain  it  here  also,  with  or  with- 
out gas,  and  oxygen-ether  is  universally  applicable.  Dr. 
Adamson  has  acted  as  anaesthetist  at  every  operation,  and 
she  has  kindly  written  the  following  brief  account  of  her 
method  and  experience: 

Method  of  Ansesthesia  for  Intrathoracic  Operations. — 
The  method  of  obtaining  a  satisfactory  ansesthesia  for 
intrathoracic  operations  involved  very  httle  difficulty 
after  the  first  three  or  four  cases.  The  first  cases  were 
frankly  experimental  from  the  point  of  view  both  of  the 
depth  of  anaesthesia  required  and  of  the  means  by  which 
this  might  be  brought  about.  The  method  has  now  been 
stereotyped  in  its  essential  points,  and  only  calls  for  varia- 
tions to  meet  minor  differences  in  individual  patients:  the 
patients  have  all  been  young  men  from  19  to  34  years,  in 
sound  condition  resulting  from  mihtary  training,  and  im- 
mediately before  operation  have  been  free  from  any  infec- 
tion giving  rise  to  a  high  temperature.  Many  of  them 
have  required  a  large  amount  of  anaesthetic. 

The  anaesthetic  used  for  all  the  cases  has  been  ether, 
administered  through  a  Hewitt's  wide-bore  apparatus. 
This  has  been  chosen  for  the  following  reasons:  the  ether 
has  acted  to  a  certain  extent  as  a  respiratory  stimulant  in 
cases  which  have  had  to  carry  on  their  whole  respiratory 
function  with  one  lung  only ;  and  for  the  convenience  of  the 
operator  the  depth  of  the  anaesthesia  has  needed  to  be  so 
great  that  chloroform  administered  to  such  a  degree  would 
have  been  extremely  dangerous. 


THE  SURGERY  OF  THE  CHEST  215 

Having  chosen  ether  as  the  more  suitable  anaesthetic, 
and  considering  it  unwise  to  give  any  chloroform  at  all,  it  is 
obviously  impossible,  with  this  class  of  patient,  to  induce 
a  satisfactory  anaesthesia  by  the  open  method.  The 
closed  inhaler  has  been  used  throughout  the  series  of  cases. 
A  positive-pressure  apparatus  was  not  used,  as  the  surgeon 
wished  for  a  collapsed  lung. 

In  the  earlier  cases  nitrous  oxide  gas  was  used  to  begin 
the  induction,  but  has  been  discontinued  because  of  a 
tendency  to  persistent  cyanosis  which  appeared  in  some  of 
the  patients  who  were  already  the  subjects  of  varying  de- 
grees of  dyspnoea. 

Before  coming  to  the  theatre  the  patients  are  given  a 
preliminary  hypodermic  injection  of  morphine  gr.  ^,  sco- 
polamine gr.  1^,  and  atropine  gr.  y^,^,  half  £m  hour  before 
the  induction  of  general  anaesthesia.  This  preliminary  in- 
jection overcomes  the  agitation  some  of  the  patients  show 
at  the  prospect  of  what  is  to  them  an  alarming  operation, 
and  it  edso  overcomes  any  trouble  from  excessive  saUvary 
or  bronchial  secretions. 

Induction  is  begun  with  the  Hewitt's  apparatus  with- 
out the  bag,  the  proportion  of  ether  being  increased  from 
nothing  to  the  full  strength  possible.  When  this  point  is 
reached,  and  when  the  patient  is  breathing  easily,  the  bag 
is  fixed  to  the  apparatus  and  used  until  the  completion  of 
the  operation.  For  most  patients  the  anaesthesia  pro-- 
duced  by  this  method  alone  is  insufficient,  and  then  the 
strength  of  ether  vapour  is  increased  by  placing  the  bag  in 
a  bowl  of  hot  water  and  also  by  surrounding  the  ether  con- 
tainer with  a  swab  wrung  out  of  hot  water.  With  this 
added  help  it  has  practically  always  been  possible  to  ob- 
tain the  required  depth  of  anaesthesia,  however  powerful 


216  ESSAYS  ON  SURGICAL  SUBJECTS 

and  resistant  the  patient,  provided  this  has  been  carried 
out  before  the  pleural  cavity  is  opened. 

From  the  outset,  anaesthesia  is  pushed  to  a  considerable 
depth,  allowing  of  complete  muscular  relaxation,  and  for  a 
few  minutes  before  the  pleural  cavity  is  opened  the  end  of  a 
flexible  rubber  tube  connected  with  an  oxygen  cylinder  is 
introduced  under  the  edge  of  the  face-piece  of  the  inhaler 
and  a  gentle  stream  of  oxygen  allowed  to  pass  along  it. 
The  face-piece  is  then  kept  shghtly  tilted  to  prevent  over- 
distention  of  the  bag  with  oxygen,  but  it  is  not  removed 
periodically  to  give  the  patient  a  breath  of  fresh  air  as  is 
usual  when  employing  a  closed  inhaler  for  other  operations. 

At  the  time  of  the  incision  of  the  pleura  the  patient  is 
deeply  anaesthetized,  breathing  evenly  and  slowly,  and  his 
colour  is  bright  red  from  the  inhalation  of  an  excess  of 
oxygen.  Directly  the  pleural  cavity  is  opened,  the  lung, 
if  free  from  adhesions,  collapses,  and  the  patient  stops 
breathing.  The  period  of  apnoea  varies  from  a  few  seconds 
to  one  or  two  minutes.  The  pulse  remains  regular,  and 
usually  unchanged  in  rate.  In  a  few  cases  the  rate  has 
been  increased  by  ten  to  twenty  beats  a  minute  for  a  few 
minutes  and  has  then  returned  to  its  previous  rate.  The 
patient's  colour  has  remained  bright  red. 

Breathing  reconmiences  at  about  the  previous  rate, 
but  the  range  of  respiration  is  extremly  shaUow,  and  re- 
mains so  until  the  end  of  the  operation.  For  this  reason  it 
is  essential  that  the  opening  of  the  pleural  cavity  shall  be 
delayed  until  a  satisfactory  deep  anaesthesia  is  obtained,  as 
it  has  been  found  quite  impossible  to  repair  the  omission 
later.  The  stream  of  oxygen  is  continued  during  the 
whole  operation,  and  may  need  to  be  slightly  increased  for 
a  short  time  after  the  resumption  of  respiration  following 
the  period  of  apnoea.    The  anaesthesia  produced  in  this 


THE  SURGERY  OF  THE  CHEST  217 

way  is  sufficient  to  allow  of  the  necessary  manipulation  of 
the  lung  and  freeing  of  adhesions,  the  dehvery  of  the  lung 
through  the  wound  to  allow  of  thorough  examination,  and 
the  stitching  of  any  bleeding  wound  in  the  lung  or  its  root. 
In  cases  which  have  involved  manipulation  of  the  heart 
there  has  been  a  temporary  weakening  of  the  pulse  corre- 
sponding to  any  definite  pressure  on  the  heart.  There  has 
been  no  irregularity  or  missing  of  heart-beats  noticed  from 
this  cause. 

At  the  end  of  the  operation  the  patient's  colour  is  usu- 
ally bright  red,  the  respirations  are  still  shallow  and  regu- 
lar, and  the  pulse  is  of  the  quahty  that  it  was  at  the  begin- 
ning. In  most  cases  the  administration  of  oxygen  has 
been  stopped  directly  the  pleural  cavity  has  been  closed, 
and  the  patient  has  remained  comfortable  and  of  good 
colour  on  his  return  to  bed.  In  a  few  cases  the  respira- 
tions have  been  too  shallow  to  maintain  a  satisfactory 
oxygenation  of  the  blood,  and  the  patient  has  become 
markedly  cyanosed  and  his  pulse  has  begun  to  fail.  This 
unsatisfactory  condition  has  been  remedied  by  administer- 
ing small  quantities  of  oxygeh  at  intervals,  whenever  the 
patient's  colour  becomes  in  the  least  blue. 

The  only  real  difficulty  in  connection  with  the  anaes- 
thesia for  intrathoracic  operations  is  in  obtaining  a  suffi- 
cient depth  in  the  patients  who  require  a  large  amount  of 
anaesthetic  to  produce  even  unconsciousness.  If  the  pa- 
tient is  insufficiently  anaesthetized  he  is  the  subject  of  a 
most  troublesome  cough  and  straining  each  time  an  at- 
tempt is  made  to  touch  the  lung.  This  greatly  hampers 
the  operation,  and,  owing  to  the  shallow  respiration  and 
consequent  small  amount  of  anaesthetic  inhaled  when  the 
pleural  cavity  is  opened,  it  is  practically  impossible  to 
deepen  the  anaesthesia  at  this  stage. 


218  ESSAYS  ON  SURGICAL  SUBJECTS 

On  this  account  it  should  be  emphasized  that  it  is 
essential  to  secure  a  complete  anaesthesia  without  cyanosis 
before  the  pleural  cavity  is  opened,  even  if  it  leads  to  ap- 
parent delay  in  the  operation. 

The  Use  of  x-Rays  During  Operation. — The  perform- 
ance of  operations  for  the  removal  of  foreign  bodies,  in  all 
parts  of  the  body,  under  the  x-rays  has  been  almost  uni- 
versally practised  in  France,  where  special  operation  tables 
have  been  devised,  and  where  the  radioscopic  "bonnet" 
has  been  perfected.  Comparatively  httle  use  has  been 
made  in  the  British  Army  of  such  methods.  Various  criti- 
cisms of  an  a  priori  kind  have  been  brought  against  the 
French  methods.  It  is  said  that  the  operator  does  not 
know  where  his  instrument  is  going  when  it  is  pushed 
directly  through  the  tissues  of  the  limb  or  the  chest,  from 
the  surface  to  the  foreign  body;  that  vessels  or  nerves  may 
be  encountered  unwittingly  and  seriously  damaged,  with 
grave  consequences;  that  the  foreign  body,  even  when 
reached,  may  not  be  easily  grasped ;  and  that  the  forcible 
and  rough  withdrawal  of  a  foreign  body,  perhaps  heavily 
infected,  through  sound  tissues  may  be  the  cause  of  an 
acute  recrudescence  of  sepsis  in  the  wound.  It  is  said 
that  such  operations  are  "groping  in  the  dark,"  and  that  a 
method  is  "unsurgical"  which  does  not  allow  the  operator 
to  see  what  he  is  doing  and  where  he  is  going.  I  confess 
that  I  feel  a  certain  sympathy  with  all  these  objections; 
but  they  are,  I  now  reahze,  quite  invalid.  The  success,  not 
of  a  few  cases  but  of  many  thousands,  has  shown,  I  think 
indisputably,  that  the  screen  methods  are,  on  the  whole, 
and  in  properly  chosen  cases,  safer  than  the  open  methods, 
and  that  their  after-consequences  are  at  least  as  tranquil. 
To  the  criticism  that  the  operations  are  "bhnd,"  the  ex- 
pert French  surgeon  replies  that,  on  the  contrary,  under  the 


THE  SURGERY  OF  THE  CHEST  219 

screen  he  sees  exactly  what  he  is  doing,  and  that,  when  the 
foreign  body  has  been  accurately  locahzed,  he  knows  pre- 
cisely what  structure  he  may  meet,  and  what  structure  he 
must  avoid.  And  he  will  point  to  a  very  long  series  of 
cases  to  show  that  the  fear  of  infection  of  the  track  along 
which  the  metal  is  withdrawn  is  excessively  small.  It  is 
admitted,  of  course,  that  the  methods  have  not  a  universal 
apphcation.  There  are  regions,  Hke  the  heart  or  the  hilum 
of  the  lung,  that  must  always  be  approached  by  the  open 
method.  And  there  are  projectiles  so  large  that  they  can- 
not be  withdrawn  from  the  chest  in  the  narrow  space  be- 
tween two  ribs.  The  work  needs  a  special  brief  education ; 
but  the  fact  that  the  technique  is  by  no  means  especially 
difficult  is  shown  by  its  wide  adoption  by  the  army  sur- 
geons in  France,  and  by  the  success  which  has  attended  it 
in  all  hands. 

Whatever  operation  is  practised  upon  the  chest,  the 
most  accurate  locahzation  of  the  foreign  body  by  a;-rays  is 
desirable;  and  the  condition  of  the  lung,  the  presence  of 
pleural  adhesions,  and  the  range  of  movement  in  the  dia- 
phragm, should  all  be  investigated.  My  colleague,  Dr. 
H.  B.  Scargill,  who  has  conducted  all  the  radiological 
examinations  in  my  cases,  has  kindly  written  the  follow- 
ing brief  note. 

Radiological  Examination. — This  resolves  itself 
into  three  parts: 

1.  The  Localization  of  the  Foreign  Body  Should  be  as 
Accurate  as  Possible. — It  is  advisable  to  mark  the  position 
of  the  foreign  body  on  both  anterior  and  posterior  surfaces, 
and  to  indicate  the  distance  of  the  foreign  body  from  each. 

The  radiograph  should  always  be  taken  from  the  sur- 
face nearer  to  the  foreign  body.    The  depth  from  the  sur- 


no  ESSAYS  ON  SURGICAL  SUBJECTS 

face  can  be  ascertained  by  any  of  the  usual  methods.  It  is 
advisable  to  make  observations  from  the  anterior  and 
posterior  surfaces  as  a  means  of  checking  the  result  ob- 
tained. 

2.  The  Screen  Examination  of  the  Chest. — If  the  metal 
moves  downwards  on  deep  inspiration,  it  must  be  in  the 
lung,  or  embedded  in  the  diaphragm. 

If  in  the  root  of  the  lung  the  movement  is  downward, 
but  is  very  slight  indeed. 

If  the  movement  is  upward  on  inspiration,  the  metal  is 
either  (a)  in  the  chest  waU,  or  (6)  in  a  portion  of  the  lung 
which  is  firmly  adherent  to  the  chest  wall  and  can  only 
move  with  the  chest  wall. 

3.  The  Examination  for  Adhesions  of  the  Lung  and 
Chest  Wall. — In  the  lower  part  of  the  chest,  the  movement 
of  the  arch  of  the  diaphragm  on  the  affected  side  is  most 
important  as  an  indication  of  the  degree  of  expansion  of 
the  lung. 

Around  a  part  of  the  lung  which  is  adherent  to  the  chest 
wall  there  is  generally  patchy  opacity  to  be  seen,  due  to 
thickening  of  the  pleura.  In  some  cases  the  lung  and 
pleura  may  appear  quite  translucent,  and  yet  at  operation 
there  may  be  found  very  firm  adhesions. 

Adhesions  can  only  be  seen  as  opacities  when  there  is 
thickening  of  the  pleiu'a  of  long  standing. 

Indications  for  Operation 

So  far  as  our  present  knowledge  goes,  the  indications 
for  operation  seem  to  be: 

1.  The  Continued  Presence  of  Subjective  Symptoms. — 
A  full  account  of  these,  as  seen  in  my  own  cases,  has  been 
already  given.  In  all  the  cases  I  have  dealt  with  by  opera- 
tion the  complaints  have  been  real,  and  the  distress,  in  the 


THE  SURGERY  OF  THE  CHEST  221 

patient's  opinion,  has  been  ample  warrant  for  his  submis- 
sion to  an  operation,  the  perils  of  which  I  did  nothing  to 
behttle.  It  must  be  admitted  that  in  many  patients  a 
degree  of  apprehension  with  regard  to  their  condition 
exists,  and  that  consequently  their  subjective  phenomena 
may  lack  nothing  in  descriptive  detail.  But  an  increasing 
experience  has  shown  that  the  x-ray  disclosures  and  the 
conditions  found  at  operation  often  account  for  the  pres- 
ence of  symptoms  which  had  been  ascribed  to  "functional'* 
causes.  The  presence  of  thick  masses  of  adhesions,  which 
revealed  httle  or  no  evidence  on  auscultation  or  percussion 
— especially  adhesions  to  the  diaphragm — will  account  for 
many  legitimate  complaints  of  pain  in  the  mediastinal 
regions,  or  in  the  abdomen.  It  is  not  so  much  the  mere 
presence  of  a  foreign  body  in  the  lung  that  should  be  con- 
sidered, but  rather  the  various  changes  in  the  lung  and  in 
the  pleura  which  result  from  the  original  injury,  and  which 
are  chiefly  the  cause  of  symptoms  and  chiefly  in  need  of 
relief. 

2.  The  Conditions  of  the  Foreign  Body  and  of  the  Lung 
Surrounding  It. — The  foreign  body  induces  certain  changes 
in  the  parts  of  the  lung  in  its  immediate  neighbourhood. 
These  are  described  elsewhere.  A  complete  investment  of 
the  foreign  body  by  a  fibrous  covering  is  rare.  Only  once 
have  I  seen  a  piece  of  metal  so  closely  covered  on  aU  sides 
as  to  be  isolated  from  lung  tissue  and,  so  far  as  could  be 
judged,  incapable  of  inflicting  further  injury  on  the  paren- 
chyma. Conditions  which  are  those  of  perfect  and  perma- 
nent tolerance  of  a  foreign  body  are,  therefore,  extremely 
rare.  Around  the  foreign  body  the  physical  conditions  of 
the  lung,  however  altered,  are  rendered  more,  rather  than 
less,  hkely  to  be  made  active  by  the  presence  of  an  irritat- 
ing or  infected  piece  of  metal  or  of  clothing.     If  we  take 


222  ESSAYS  ON  SURGICAL  SUBJECTS 

into  account  the  character  of  the  foreign  bodies  retained, 
the  physical  properties  of  the  tissue  in  which  they  are  held, 
the  incessant  movement  of  the  chest,  the  high  degree  of 
physiological  activity  present  in  the  lung,  and  the  number 
and  size  of  the  vessels  in  the  chest  and  in  the  lung  tissue, 
it  is  probably,  as  a  rule,  wiser  to  advise  removal  of  the 
foreign  body  than  to  sanction  its  retention. 

3.  The  Conditions  of  the  Pleural  Cavity. — In  many  cases 
that  I  have  operated  upon  pleural  adhesions  were  present 
in  a  degree  that  alone  would  cause  a  restriction  of  the  ac- 
tivities of  the  lung.  In  such  cases  the  measurements  of 
the  chest  on  the  affected  side  are  smaller;  dullness  may  be 
present  in  some  degree;  and  there  is  deficient  entry  of  air 
into  the  chest.  The  sinking  in  of  the  chest  wall,  the  col- 
lapse of  the  lung,  and  the  pulUng  over  of  the  whole  medias- 
tinum, are  results  of  the  pleural  injury  and  the  patholog- 
ical conditions  subsequently  developed,  and  are  causes  of 
the  respiratory  and  other  difficulties  of  which  an  account 
is  given  elsewhere. 

It  is  important  to  know  to  what  extent  these  conditions 
can  be  reheved  by  operation.  Speaking  broadly,  two  types 
of  operations  are  performed  in  such  cases — the  method  of 
Petit  de  la  ViUeon,  and  the  open  method.  In  the  former, 
nothing  is  done  to  alter  the  physical  conditions  within  the 
chest  cavity  other  than  the  removal  of  the  foreign  body. 
In  the  latter,  all  adhesions  are  separated,  masses  of  lymph 
dissected  off  the  lung  and  the  diaphragm,  and  a  consider- 
able attempt  made  to  cause  a  return  of  the  conditions  to 
the  normal.  How  far  such  efforts  are  successful  is,  with 
the  evidence  at  my  disposal,  a  matter  of  doubt.  If  there 
has  been  an  empyema  before  the  operation,  I  think  the 
conditions  in  my  own  cases  have  not  been  improved. 
This  may  possibly  be  due  to  a  too  early  operation  in  which 


THE  SURGERY  OF  THE  CHEST  223 


infection  has  been  freshly  aroused,  here  as  elsewhere,  by 
precocious  interference.  If  adhesions  have  been  extensive 
and  dense,  their  removal  has  certainly  given  increased  free- 
dom to  the  action  of  the  lung.  The  records  of  my  cases 
show  that  benefit  has  almost  always  resulted  in  such  cases. 
Improvement  does  not  occur  in  the  same  degree  or  so 
rapidly  if  no  operation  is  done;  for  in  patients  whom  I 
have  kept  under  observation  for  months  before  operation, 
the  change  in  the  condition  of  the  chest  on  examination, 
chnically  or  by  aj-rays,  and  the  improvement  in  their  sub- 
jective disturbances,  has  been  either  absent  or  exceedingly 
small.  Open  operation  may  therefore  be  said  to  be  justi- 
fied by  its  results. 

Methods  of  Operation 

The  methods  which  have  been  practised  for  the  re- 
moval of  foreign  bodies  from  the  chest  will  be  considered 
in  the  following  order:  (1)  Method  of  Petit  de  la  Villeon;  (2) 
Method  of  Marion;  (3)  The  open  method  of  Duval;  (4)  Opera- 
tions upon  the  hilum  of  the  lung;  (5)  Operations  upon  the 
mediastinum. 

1.  Method  of  Dr.  Petit  de  la  Villeon. — The  operation 
consists  in  the  introduction,  through  a  very  small  incision 
made  between  two  ribs,  of  a  special  pair  of  forceps,  with  a 
blunt  end  and  long  parallel  blades  on  the  one  side  of  the 
hinge,  and  short  "crocodile-jaw"  blades  on  the  other.  The 
position  of  the  foreign  body  is  very  accurately  determined 
by  the  x-ray.  The  operation  is  performed  under  the  x-ray 
and  with  the  aid  of  the  screen.  A  preliminary  injection  of 
morphine  is  given  and  a  light  general  anaesthesia  induced. 
Petit  de  la  Villeon  uses  chloroform.  The  forceps  are  in- 
troduced from  the  axillary  side,  the  incision  to  admit  them 
being  made  along  the  upper  border  of  the  rib,  so  as  to 


224  ESSAYS  ON  SURGICAL  SUBJECTS 

avoid  vessels,  and  are  guided  by  the  image  on  the  screen 
and  directed  towards  the  known  position  of  the  foreign 
body.  The  progress  of  the  instrument  is  slow  and  gentle, 
and  continues  until  the  image  of  the  tip  of  the  forceps  and 
of  the  foreign  body  coincide.  If  the  entry  has  been  ex- 
pertly made  the  contact  will  then  be  felt;  the  metal  is 
grasped  by  the  wide  opening  of  the  * 'crocodile-jaw'* 
blades,  and  is  slowly  and  steadily  withdrawn.  Nothing 
remains  but  to  close  the  skin  wound  by  a  single  stitch. 
The  penetration  of  a  blunt  forceps  into  the  lung  tissue  does 
no  damage.  It  ruptures  no  vessels ;  it  does  no  injury  to  the 
dehcate  tissues  of  the  lung;  it  seems  to  cause  a  separation 
of  the  tissues  rather  than  a  destruction  of  them.  The  ex- 
perience of  recent  wounds  of  the  lungs  in  this  war  has 
shown  how  very  tolerant  of  injury  they  are,  and  how  few 
are  the  symptoms  produced  by  the  slighter  degrees  of 
trauma.  It  is  not  then  surprising  to  hear  that  a  blunt 
instrument  may  be  gently  pushed  through  the  lung  sub- 
stance without  giving  rise  to  any  real  danger.  The  with- 
drawal of  a  foreign  body  might  be  attended  by  more  se- 
rious injury,  especially  if  there  were  many  sharp  points  and 
rough  surfaces;  these,  however,  do  not  inflict  much  injury, 
if  any,  if  the  jaws  of  the  forceps  grasp  and  include  the  for- 
eign body  in  their  embrace.  Such  damage  as  is  caused 
would  be  enhanced  in  severity  if  the  metal  chanced  to  be 
infected  by  one  or  more  organisms,  which  we  know  will  re- 
main potentially  active  in  the  lung  for  years.  But  sup- 
positions and  fear  must  yield  to  experience;  and  this  has 
given  abundant  proof,  in  the  hands  of  all,  that  the  risks 
of  injury  are  almost  neghgible.  The  mortahty  has  been 
found  to  be  extremely  small,  far  less  than  by  any  other 
operation  practised.  The  post-operative  course  is  so 
smooth  and  devoid  of  incident  as  to  excite  the  frank  as- 


THE  SURGERY  OF  THE  CHEST  225 

tonishment  of  all  who  see  the  method  practised  for  the 
first  time.  The  functional  recovery  is  said  to  be  at  least 
as  good  as  that  which  follows  the  open  operations;  and  is 
obtained  at  less  risk  and  less  cost  in  respect  of  suflFering 
and  dm'ation  of  convalescence. 

There  are  certain  contra-indications  to  the  method: 
(a)  Proximity  of  the  Foreign  Body  to  the  Hilum  of  the 
Lung. — One  of  the  few  fatahties  in  the  large  series  of 
cases  operated  upon  by  Petit  de  la  Villeon  occurred  as  the 
result  of  haemorrhage  after  extraction  of  a  piece  of  metal 
from  the  hilum.  He,  and  every  other  surgeon,  now  agrees 
that  for  all  retained  projectiles  in  this  position  an  open 
operation  is  necessary.  It  is  imperative  that  the  work  to 
be  done  should  be  carried  out  under  open  inspection,  and 
that  steps  should  be  taken  to  avoid  laceration  of  the  large 
and  numerous  vessels  in  the  root  of  the  lung,  and  to  arrest 
such  haemorrhage  as  occiu's  either  by  suture  or,  as  Petit 
de  la  Villeon  prefers,  by  packing  with  gauze  for  two  or 
three  days. 

(6)  Proximity  of  the  Foreign  Body  to  the  Heart. — In  one 
of  his  cases  reported  in  Bull,  et  Mem.  Soc.  de  Chir.  de  Paris^ 
1918,  p.  577,  Petit  de  la  ViUeon  describes  the  projectile 
as  "appearing  to  be  included  in  the  wall  of  the  left  ven- 
tricle of  the  heart."  It  was  extracted  by  his  method,  the 
forceps  passing  through  the  entire  thickness  of  the  lower 
lobe  of  the  left  lung.  In  another  case  some  fibres  of  heart 
muscle  were  found  on  the  missile  after  removal.  In  his 
most  skilful  hands  the  method  does  not  appear  to  have 
presented  unusual  difiiculties  or  serious  dangers;  but  it  is 
nevertheless  one  to  be  condemned.  In  all  cases  where  the 
projectile  is  adherent  to  the  surface  of  the  heart,  or  in 
which  the  lung  is  so  adherent  to  the  pericardiiun,  and  this 
membrane  to  the  heart,  that  it  is  impossible  to  say  how 

15 


226  ESSAYS  ON  SURGICAL  SUBJECTS 

close  the  connection  between  the  missile  and  the  heart  may 
be,  the  open  operation  alone  should  be  practised. 

(c)  The  Size  of  the  Projectile. — The  great  majority  of 
the  foreign  bodies  lodged  in  the  parenchyma  of  the  lung 
are  of  so  small  a  size  as  to  allow  of  their  easy  extraction 
between  the  ribs.  If  the  projectile  is  large,  a  piece  of  rib 
may  be  resected,  or  raised,  and  the  remainder  of  the  opera- 
tion conducted  in  the  usual  manner.  But  even  then  the 
damage  done  to  the  lung  by  the  forcible  dragging  through 
its  tissues  of  a  large  sohd  body  must  be  taken  seriously  into 
account.  For  large  projectiles  the  open  operation  is  either 
the  only  possible  method,  or  the  safer. 

(d)  Suppuration  Round  the  Projectile. — This  can  gener- 
ally be  determined  by  the  radiologist.  When  it  is  evident 
that  a  small  abscess  surrounds  the  foreign  body,  or  that 
it  is  encased  in  a  hard  sclerotic  mass,  it  is  unwise  to  attempt 
the  removal  by  this  method.  It  is  impossible  to  say 
whether  the  pus  which  lies  on  all  sides  of  the  missile  is 
heavily  infected  or  no.  But  it  is  well  to  take  no  risks. 
The  removal  of  the  foreign  body  in  all  such  cases  should  be 
done  under  full  inspection,  so  that  an  adequate  cleansing 
of  the  infected  cavity  may  be  secured. 

(e)  The  Presence  of  Other  Foreign  Bodies  than  that  Shown 
on  the  Screen. — It  is  not  often  that  pieces  of  clothing  are 
found  with  the  projectiles  in  the  parenchyma  of  the  lung. 
I  know  no  explanation  for  this :  but  it  is,  in  my  experience, 
far  less  frequent  to  find  debris  of  clothing  in  the  lung  than 
in  the  limbs,  when  pieces  of  metal  are  being  removed. 
The  danger  of  leaving  behind  a  piece  of  cloth  is  therefore 
very  slight,  and  the  subsequent  clinical  history  of  a  large 
number  of  cases  shows  that  the  risk  is  one  that  need  hardly 
be  considered.  Petit  de  la  Villeon  believes  that  in  many 
cases  he  removes  not  only  the  foreign  body  but  its  cap- 


THE  SURGERY  OF  THE  CHEST  227 


sule,  and  any  other  foreign  body  included  in  it.  Such 
an  experience  must,  I  am  sure,  be  exceedingly  infrequent. 

The  essential  circumstance  for  the  successful  extrac- 
tion of  the  projectile  by  this  method  is  its  mobility  with  the 
lung.  This  is  indicated  by  the  ic-ray ;  the  shadow  of  the 
foreign  body  should  move  downwards  concomitantly  with 
the  diaphragm.  The  exception  is  in  the  case  of  foreign 
bodies  in  the  apex  of  the  lung,  where  the  range  of  move- 
ment is  shght  or  absent.  This  freedom  of  motion  indi- 
cates that  the  metal  is  not  embedded  in  a  mass  of  dense 
adhesions  outside  the  lung,  extrication  from  which  would 
involve  gross  and  heavy-handed  measures.  The  benig- 
nity of  the  operation  is  remarkable.  It  is  rare  for  a  patient 
to  be  incapable  of  discharge  from  hospital  in  eight  or  ten 
days. 

It  has  often  been  asserted  that  the  method  is  a  "blind" 
one;  that  the  surgeon  is  "groping  in  the  dark";  and  that  it 
is  easy  to  lose  one's  way  and  to  be  compelled  to  pierce  the 
lung  in  several  directions  until  contact  with  the  metaUic 
foreign  body  is  made.  All  these  things  depend  upon  the 
surgeon.  To  render  it  not  a  "bhnd"  but  an  open  method 
— a  "clairvoyant  method" — it  is  necessary  for  the  operator 
to  become  practised  in  screen  examinations,  and  to  make 
himself  an  adept  in  the  removal  of  projectiles  from  the 
limbs.  As  Petit  de  la  Villeon  says,  an  apprenticeship  is 
necessary.  This  is  hardly  an  objection,  or  if  it  is,  it  has  a 
wide  apphcation.  The  method  has  on  many  occasions 
been  controlled  in  this  way:  the  small  external  incision 
has  been  made,  the  lung  pierced,  the  forceps  left  in  sitUy 
and  the  chest  opened  to  remove  a  foreign  body  whose 
fibrous  casing  has  been  dense,  or  whose  situation  in  the 
diaphragm  has  made  withdrawal  difficult.  An  inspection 
of  the  lung  has  shown  only  a  shght  bruise  at  the  point  of 


228  ESSAYS  ON  SURGICAL  SUBJECTS 

entry  of  the  forceps,  and  "not  a  drop"  of  blood  has  been 
seen  to  issue  from  the  path  made  in  the  lung. 

There  are  times  when  a  httle  air  escapes  into  the  pleural 
cavity  by  the  side  of  the  forceps.  This  is  of  no  account. 
We  Imow  by  long  experience  how  httle  is  the  harm  done 
by  a  pneumothorax  so  caused,  as,  for  example,  in  operation 
on  the  kidney  when  the  last  rib  is  removed.  Robineau, 
indeed,  holds  the  opinion  that  it  may  even  make  the  opera- 
tion easier.  He  finds  edso  that  when  the  method  is  prac- 
tised as  an  open  operation,  in  the  circumstances  just  men- 
tioned, the  movement  of  the  forceps  within  the  lung  is  al- 
ways free,  causes  no  haemorrhage,  never  lacerates  the 
lung,  but  allows  it  to  shp  forwards  and  backwards  along 
the  forceps  with  great  ease. 

The  most  alarming  consequence  which  has  followed 
upon  this  method  is  haemoptysis.  In  some  degree  this  oc- 
curs in  the  majority  of  cases ;  in  serious  degree,  very  seldom. 
Margins  records  one  case  in  which  the  haemorrhage  was 
extremely  serious  though  not  fatal. 

An  occasional  rise  of  temperature  occurs;  and  a  local- 
ized patch  of  consohdation  may  be  found.  In  one  case  P. 
Duval  lost  a  patient  from  double  pneumonia.  A  serous 
effusion  of  slight  degree  into  the  pleural  cavity  is  not  infre- 
quent. The  evidences  of  it  usually  disappear  within  four 
or  five  days. 

2.  Marion's  Method. — This  consists  in  resection  of  one 
rib  in  front,  usually  the  4th  or  5th.  When  the  pleura  is 
exposed  and  the  lung  is  visible  underneath,  a  curved 
Reverdin  needle  is  passed  through  the  pleura  into  the  lung, 
out  through  the  pleura  again,  and  the  stitch  tied.  A  series 
of  such  stitches  fix  the  lung  firmly  to  the  parietal  pleura. 
When  such  fixation  is  thought  to  be  complete,  the  pleura 
and  lung  together  are  incised.    Air  does  not  enter  the 


THE  SURGERY  OF  THE  CHEST  229 

pleural  cavity;  that  is  to  say,  no  pneumothorax  develops. 
From  the  incised  lung  air  and  blood  escape.  A  finger  is 
pushed  into  the  wound,  and  the  foreign  body  felt  and  ex- 
tracted with  the  finger;  or  a  Kocher's  forceps,  or  other  in- 
strument, is  passed  into  the  lung  until  the  foreign  body  is 
felt,  seized,  and  then  extracted.  Marion  then  passes  a 
strip  of  gauze  into  the  wound  in  the  lung  and  allows  this  to 
remain  for  a  few  days.  The  parietal  wound  is  closed 
round  the  gauze. 

I  can  see  httle  advantage  in  this  method.  The  fear  of 
pneumothorax  is  an  exaggerated  fear.  The  one  reason  for 
its  adoption  may  be  this,  that  in  cases  of  infected  foreign 
bodies  the  risk  of  conveyance  of  the  infection  is  limited  to 
the  small  track  through  the  limg  and  to  the  parietal  wound : 
it  does  not  affect  the  cavity  of  the  pleura. 

The  objection  has  been  brought  against  the  method 
that  it  creates  a  sohd  mass  of  adhesions  fixing  the  lung  to 
the  parietal  pleura.  That  is  true;  but  some  degree  of  ad- 
hesion of  the  lung  no  doubt  occurs  to  every  parietal  wound 
in  the  ordinary  open  operation,  especially  when  the  plem-al 
coaptation  has  been  imperfect,  as  it  often  is.  Some  sur- 
geons, R.  OUver,  of  Lyon,  for  example,  speak  enthusiastic- 
ally of  this  method.     (Lyon  Chir.,  1918,  xv,  351.) 

3.  The  Open  Operation  of  Duval. — The  operation  I 
have  performed  in  my  cases — a  shght  modification  of 
Duval's — is  the  following:  An  incision  is  made  exactly  in 
the  fine  of  a  rib  (Fig.  9),  following  its  curve,  from  the 
edge  of  the  sternum  outwards,  for  about  5  inches.  As  a 
rule  the  4th  rib  is  chosen.  If  the  projectile  is  in  the  apex 
of  the  lung  the  3rd  rib  may  guide  the  line  of  incision ;  if  the 
projectile  is  at  the  lower  part  of  the  chest  the  5th  rib  is 
selected.  The  room  given  for  the  introduction  of  the 
hand  is  greater,  the  lower  the  incision  is  made.    The  in- 


230  ESSAYS  ON  SURGICAL  SUBJECTS 

cision  cuts  through  the  skin,  subcutaneous  tissue,  and  pec- 
toralis  fascia,  and  exposes  the  fibres  of  the  pectoraHs 
major  muscle.  A  pair  of  forceps  is  pushed  through  the 
fibres  of  the  muscle  until  it  touches  the  rib ;  the  blades  are 
opened  and  the  muscle  is  spKt,  and  the  separation  is 
widely  made  from  end  to  end  of  the  original  incision.  The 
pectorahs  minor  is  then  exposed,  and  may  be  split  in  the 
same  manner,  or  cut  away  until  the  outer  surface  of  the 
rib  is  seen.  All  vessels  which  bleed,  and  there  are  many, 
are  carefully  hgatured,  for  a  very  dry  wound  is  essential. 

The  rib  and  costal  cartilage  are  now  well  exposed. 
Through  the  periosteum  two  incisions  are  made  close  to 
the  upper  and  lower  edges  of  the  rib,  and  from  them  the 
periosteum  is  stripped  upwards  and  downwards  and  from 
the  posterior  surface.  The  periosteum  which  hes  between 
the  two  incisions  is  not  separated  from  the  rib,  but  re- 
mains attached  to  it  through  all  the  stages  of  the  operation. 

As  soon  as  the  periosteum  is  freed  from  the  posterior 
surface  for  half  an  inch,  the  periosteal  elevator  of  Doyen  is 
slipped  round  the  rib,  and  pushed  backwards  towards  the 
axilla  and  forwards  to  and  along  the  costal  cartilage,  until 
a  length  of  about  5  inches  is  cleared.  Here  and  there  a 
little  help  may  be  needed  with  the  knife  or  scissors  to  make 
the  way  easy  for  the  instrument.  The  costal  cartilage  is 
now  divided  by  two  incisions  meeting  at  a  point  (Fig.  10) ; 
this  allows  the  divided  ends  to  dovetail  together  when  the 
operation  is  nearing  completion.  When  the  cartilage  is 
divided,  a  gauze  strip  is  passed  underneath  the  rib,  which 
is  lifted  gently  upwards  and  outwards  (Fig.  11). 

In  young  patients  the  elasticity  and  suppleness  of  the 
rib  are  remarkable.  It  is  quite  easy  to  raise  the  bone  out 
of  the  way  throughout  the  operation  and  then  to  replace  it. 
The  third  rib  does  not  lift  so  easily  as  the  lower  ribs,  being 


THE  SURGERY  OF  THE  CHEST  23i 

shorter  and  therefore  more  resistant.  In  four  cases  (three 
of  the  3rd  rib)  the  bone  has  fractured  as  the  result  of  the 
drag  made  on  it.  In  three  cases  it  was  replaced  and  united 
jfirmly.  When  the  rib  is  elevated,  the  periosteum  is  seen 
as  a  thickening  of  the  pleura  exposed  in  the  wound. 

Through  periosteum  and  pleura  a  small  incision  is 
made,  with  the  result  that,  in  the  absence  of  adhesions,  air 
slowly  enters  the  pleural  cavity,  and  the  lung  begins  to 
collapse.  It  is,  I  think,  important  to  allow  of  the  slow 
development  of  the  pneumothorax;  a  sudden  collapse  of 
the  lung  might  cause  a  little  respiratory  embarrassment. 
If  air  enters  very  slowly,  the  regular  breathing  is  hardly 
disturbed  for  more  than  a  few  seconds  or  a  minute,  and  the 
operation  can  proceed  as  tranquilly,  so  far  as  anaesthesia 
is  concerned,  as  if  it  involved  one  of  the  extremities.  Le 
Fort  is,  I  beheve,  alone  in  saying  that  an  inmaediate  wide 
opening  of  the  pleura  is  safer  than  the  practice  of  making 
a  small  incision  and  allowing  air  to  enter  slowly.  The  in- 
cision in  the  pleura  is  then  lengthened,  always  along  the 
line  of  the  periosteum,  until  there  is  room  for  the  hand  to 
pass  through  it.  The  rib-spreader  is  then  introduced 
(Figs.  11  and  12).  Tuffier's  pattern  is  the  most  easily 
worked,  and  is  very  helpful.  Separation  of  the  ribs  above 
and  below  that  which  has  been  elevated  is  always  easy 
enough.  I  have  never  found  it  necessary  to  remove  or  ele- 
vate another  rib,  or  to  divide  another  costal  cartilage  to 
allow  of  more  space  being  obtained  by  further  displace- 
ment of  the  ribs. 

An  inspection  of  the  chest  is  now  made,  and  note  is 
taken  of  any  adhesions  that  may  be  found.  The  adhesions 
vary  to  a  great  extent;  they  may  be  few  and  of  the  hghtest 
texture,  breaking  down  with  the  gentlest  handUng;  they 
may  be  almost  universal,  requiring  a  firm  effort  to  separate 


232  ESSAYS  ON  SURGICAL  SUBJECTS 

them ;  they  may  be  of  the  utmost  density,  J  inch  in  thick- 
ness, so  firm  and  strong  that  a  separation  with  the  finger 
alone  is  quite  impossible.  I  have  several  times  had  to  cut 
away,  with  the  scissors,  plates  of  lymph  as  thick  as  felt 
before  I  could  Uberate  the  compressed  lung.  As  such  ad- 
hesions are  removed,  the  lung  is  seen  to  expand.  It  has 
been  my  practice  always  to  separate  every  adhesion  as  the 
first  part  of  the  intrapleural  stage  of  the  operation. 

I  have  felt,  rightly  or  wrongly,  that  the  restriction  of 
the  free  expansion  of  the  lung  by  adhesions  was  to  be  con- 
sidered as  perhaps  the  most  essential  point  of  the  opera- 
tion. Tl^e  separation  of  adhesions,  except  those  of  the 
toughest  sort,  is  best  carried  out  by  the  procedure  of 
"gauze  stripping"  which  is  adopted  in  the  separation  of  a 
hernial  sac.  On  separating  adhesions,  cavities  containing 
old  blood-clot  may  be  found.  On  one  occasion  such  a 
cavity  contained  not  less  than  a  pint  and  a  half  of  old 
blood-stained  fluid  of  the  colour  and  consistency  of  thick 
cocoa.  On  two  occasions  I  have  found  the  remains  of  an 
empyema  which  had  not  been  opened.  These  conditions 
could  not  be  discovered  unless  the  adhesions  were  method- 
ically and  habitually  separated.  The  adhesions  bleed 
freely,  but  the  haemorrhage  is  very  easfly  and  rapidly 
checked  by  the  pressure  of  hot  moist  swabs,  one  or  two 
being  left  in  the  cavity  while  the  operation  proceeds.  I 
have  sometimes  felt  the  projectile  drop  into  my  hand  as 
the  adhesions  were  being  separated;  the  foreign  bodies  lay 
not  so  much  in  the  lung  tissue  as  in  adhesions  binding  the 
two  pleural  surfaces  together. 

When  the  lung  is  freed  the  projectile  may  be  sought. 
It  is  easier  to  find  a  metaUic  foreign  body  in  the  lung  than 
in  any  other  part  of  the  body.  When  the  organ  is  gently 
grasped  in  the  fingers  a  local  hardness  is  felt  at  once.    The 


Fig,  9. — ^The  skin  incision  follows  the  line  of  the  fourth  rib. 


Kg.  10. — Division  of  the  costal  cartilage. 


Fig.  11. — ^TufSer's  rib-retractor  introduced  separates  third  from  fifth  rib 
widely.  Incision  of  periosteum  and  pleura.  The  rib  is  lifted  out  of  the  way; 
as  a  rule  it  is  raised  higher  than  is  here  shown. 


Fig.  12. — ^The  hand  intrudiutd  into  the  pleura  to  separate  adhesions,  etc. 


Fig.  13. — ^The  lung  brought  out  on  to  the  surface  of  the  chest. 


THE  SURGERY  OF  THE  CHEST  233 

part  of  the  lung  which  holds  the  metal  is  then  brought  to 
the  surface.  It  is  astonishing  to  find  with  what  ease  the 
posterior  part  of  the  lung,  for  example,  can  be  brought 
forward  to  the  wound,  and  held  there  while  the  foreign 
body  is  extracted.  The  mobihty  of  the  lung,  and  the  ease 
of  handhng  it,  are  very  remarkable.  The  lung  may  be 
grasped  with  the  hand,  or  held  Hghtly  in  the  specially  de- 
vised lung  forceps  of  Duval  (Fig.  13),  the  grasp  of  which 
is  firm  and  dehcate.  When  the  lung  containing  the  pro- 
jectile has  been  lifted  forward,  the  depth  of  the  missile 
from  the  surface  is  gauged,  and  steps  are  taken  to  remove 
the  metal.  A  pair  of  blunt  forceps  may  be  pushed  through 
the  lung  substance  until  they  impinge  on  the  bullet,  the 
blades  are  opened,  and  the  body  is  grasped  and  gently  dis- 
entangled from  the  lung.  Or  an  incision  may  be  made 
through  the  lung  directly  down  to  the  body  (Fig.  14), 
which  is  laid  bare  and  removed.  The  wound  in  the  lung 
is  now  touched  with  pure  carbohc  acid,  and  closed  by  cat- 
gut sutures  which  closely  approximate  the  pleural  edges. 

The  condition  of  the  lung  around  the  retained  metal 
varies.  Sometimes  a  small  abscess  cavity  is  discovered, 
the  pus  being  dried  and  hard;  sometimes  a  hard  fibrous 
mass  encases  the  metal;  sometimes  there  is  a  dark-red 
area  of  hepatization;  quite  often  there  is  no  appreciable 
change  in  the  density  or  appearance  of  the  lung  tissue. 

Throughout  all  the  manipulations  the  lung  is  handled 
with  extreme  gentleness.  The  fight  hand  and  the  tender 
caress  are  as  necessary  in  this  branch  of  surgery  as  in  all 
abdominal  operations,  and  equally  repay  the  surgeon  in 
the  quick  and  quiet  recovery  of  his  patients.  The  heavier 
the  handhng  of  the  lung,  the  greater  appears  to  be  the  sub- 
sequent respiratory  distress  from  which  the  patient  suffers. 

The  wound  in  it  being  closed,  the  lung  is  allowed  to 


23^  ESSAYS  ON  SURGICAL  SUBJECTS 

drop  back  into  the  chest,  and  pains  are  taken  to  see  that  all 
the  fluid  is  removed.  Bleeding  must  be  checked  by  pres- 
sure, for  the  exudation  of  even  four  or  five  ounces  on  the 
day  following  operation  is  enough  to  cause  distress.  The 
retractor  is  now  removed,  and  steps  are  taken  to  close  the 
pleural  wound.  I  have  rarely  been  able  to  close  the  pleura 
with  that  perfect  coaptation  of  the  surfaces  that  is  so  eas- 
ily obtainable  in  the  peritoneum.  The  apposition  is  often 
very  difficult,  especially  at  the  inner  end  of  the  wound, 
and  the  stitch  may  cut  through  if  any  special  tension  is 
put  upon  it  (Fig.  15).  Help  may  be  obtained  by  passing 
one  strong  suture  round  the  ribs  above  and  below,  and 
dragging  them  closely  together. 

In  early  operations  I  wiped  the  lung  wound  over  with 
ether  and  left  a  Httle  ether  in  the  chest  cavity.  It  rapidly 
evaporated,  and  at  the  completion  of  the  operation  I  as- 
pirated the  chest,  drew  the  ether  vapour  away,  and  al- 
lowed the  lung  ta  expand  at  once.  This  is  neither  neces- 
sary nor  prudent,  for  the  collapse  of  the  lung  helps  haemo- 
stasis,  and  the  air  left  in  the  pleura  is  very  rapidly  ab- 
sorbed. 

The  rib  is  now  replaced:  a  stout  catgut  suture  passed 
through  the  costal  cartilage  holds  the  ends  in  apposition, 
and  this  is  helped  very  much  by  the  dovetail  incision  which 
WEis  made  to  divide  the  cartilage  (Fig.  16).  Over  the 
rib  the  pectorahs  minor  muscle  is  sutured,  and  the  fibres 
of  the  pectoralis  major  are  brought  together  by  three  or 
four  stitches.  The  pectoralis  fascia  is  carefully  sutured 
in  all  its  length,  and  finally  the  skin  is  closed  by  a  con- 
tinuous suture  (Fig.  17).  As  a  rule  no  drainage  is  used; 
but  in  two  cases  in  which  the  bleeding  was  free  I  put  a 
small  drain  in  posteriorly  for  twenty-four  hours,  and  I 
think  the  patient's  comfort  was  increased  thereby. 


Fig.  1  i.-Posilion  of  a  foreign  body  indicated,  with  the  incision  into  the  lung  to 

expose  it. 


Fi^.  !■'>• — Suliirt'  of  the  pleura. 


Fij?.  16. — The  rib  replaced  and  the  cosl.il  cartilage  sutured. 


FjnTfTTTr 


FiK.  17. — Closure  of  the  skin  wound  by  continuous  catgut  or  horsehair  suture. 
The  scratches  made  on  the  skin  ensure  accurate  apposition  of  wound  edges. 


THE  SURGERY  OF  THE  CHEST  235 

It  is  impossible  to  displace  the  hilum  towards  the  sur- 
face, and  all  the  rather  difficult  and  often  tedious  manipu- 
lations have  to  be  carried  out  inside  the  chest. 

When  the  projectile  is  on,  or  in,  the  heart  muscle,  it  is 
convenient  to  put  in  one  or  two  sutiu'es  above  and  below, 
or  to  the  sides,  so  as  to  hold  the  heart  steady  while  an 
incision  is  made.  On  one  occasion  only  I  have  found  an 
isolated  dried  hard  mass  of  calcareous  material  in  the 
lung,  which  was  possibly  a  cured  local  tuberculosis.  On 
four  occasions  fragments  of  clothing  have  been  found  lying 
with  the  projectile. 

After-course. — As  a  rule  the  after-course  is  simple. 
The  following  comphcations  may  be  seen: 

Haemoptysis. — This  has  occurred  7  times  in  49  cases. 
As  a  rule  it  is  of  the  shghtest,  and  causes  no  concern ;  once 
only  have  I  seen  a  degree  of  haemorrhage  which  could  be 
assessed  at  3  or  4  ounces,  occurring  in  the  first  twenty- 
four  hours. 

Respiratory  Distress. — This  occurs  rarely.  It  has  only 
been  noticed  in  cases  where  a  multitude  of  severe  adhesions 
had  to  be  separated,  and  the  lung  rather  heavily  handled. 
In  12  cases  an  effusion  of  blood  or  serum  has  been  dis- 
covered on  the  third  or  fourth  day,  and  aspiration  has 
given  a  relief  that  was  striking  in  proportion  to  the 
amount  of  fluid  removed. 

Emphysema. — Surgical  emphysema  has  developed  in 
several  cases,  especially  those  in  which  a  poor  apposition 
of  pleural  surfaces  was  obtained.  It  has  twice  spread 
over  the  neck  and  face.  It  has  always  rapidly  disappeared, 
and  has  never  been  a  matter  of  distress. 

Infection  of  the  Wound,  or  of  the  Pleural  Cavity.  Em- 
pyema.— In  10  cases  empyema  had  been  present  before 
operation.    There  were,  as  I  have  said,  12  cases  in  which 


236  ESSAYS  ON  SURGICAL  SUBJECTS 

effusion  of  blood  occurred  into  the  pleural  cavity  after 
operation;  of  these,  5  developed  empyema.  In  every 
such  case  the  foreign  body  was  infected.  In  the  remain- 
ing 7  cases  aspiration  was  performed,  and  the  chest  condi- 
tion rapidly  cleared  up;  in  6  of  these  cases  the  foreign  body 
was  sterile,  and  in  1  infected.  The  infection  which  occurs 
is  undoubtedly  the  result  of  contamination  of  the  wound 
at  the  time  of  operation,  for,  with  one  exception,  where 
pneumonia  occurred,  the  organisms  recovered  from  the 
wound  discharges  or  cultivated  from  the  opened  empyema 
were  identical  with  those  found  on  the  projectile.  These 
organisms  are  coliform  bacilli,  streptococci,  and  staphy- 
lococci. 

An  examination  of  the  metal  fragments  removed  shows 
that  a  prolific  growth  of  organisms  can  be  cultivated  from 
them  years  after  the  infliction  of  the  wound.  The  ques- 
tion as  to  the  wisdom  of  freeing  adhesions  in  all  directions 
in  the  presence  of  an  infected  body  will  be  referred  to  later. 

4.  Operations  Upon  the  Root  of  the  Lung. — The  root 
of  the  lung  is  that  part  of  the  pedicle  of  the  lung  at  the 
region  where  the  pleura  is  reflected  on  to  it.  The  measure- 
ments of  the  root  are  from  above  downwards  about  30  mm., 
and  from  before  backwards  about  15  to  18  nun.  The 
surface  marking  in  front  is  the  3rd  costal  cartilage  and  the 
adjacent  intercostal  spaces  on  each  side;  and,  behind,  the 
inner  end  of  the  5th  rib  and  the  adjacent  intercostal  spaces 
on  each  side.  In  the  root  of  the  lung  he  the  bronchi,  pul- 
monary artery  and  veins,  bronchial  artery  and  veins, 
lymphatic  glands  and  vessels,  and  nerves.  The  glands 
are  numerous.  The  pedicle  enters  the  lung  at  a  vertical 
notch,  the  hilum,  gibout  45  to  50  nmi.  long  and  25  nun. 
broad. 

The  special  considerations  in  connection  with  opera- 


THE  SURGERY  OF  THE  CHEST  237 

tions  upon  the  root  of  the  lung  are,  chiefly,  the  extreme 
vascularity  of  the  part,  its  fixity,  and  its  physical  proper- 
ties. 

The  number  of  vessels  is  great  and  their  size  formidable. 
A  wound  of  the  root  of  the  lung  should  be  inflicted  with 
extreme  caution,  for  if  a  vessel  is  wounded  it  is  exceedingly 
difficult  to  arrest  the  haemorrhage.  It  is  almost  impossible 
to  secure  the  vessel  and  to  hgature  it  in  the  ordinary  man- 
ner. If  a  suture  is  passed  round  the  vessel,  it  is  likely  that 
other  vessels  will  be  wounded  by  it.  For  this  reason 
many  of  the  French  surgeons  advise  the  plugging  of  the 
wound  with  gauze,  which  is  left  in  position  for  two  or 
three  days. 

One  of  my  two  fatal  cases  died  from  haemorrhage* 
The  projectile  was  embedded  in  the  root  of  the  lung. 
After  its  gentle  removal  there  was  free  haemorrhage, 
which  appeared  to  be  arrested  by  the  sutures  I  passed  for 
this  purpose.  The  patient  died  in  a  few  hours,  and  the 
pleura  was  found  filled  with  blood.  The  error  in  technique 
was  grievous,  and  the  warning  for  similar  cases  did  not  go 
unheeded. 

The  fixity  of  the  root  makes  all  operations  upon  it  far 
more  difficult  than  those  which  engage  other  parts  of  the 
lung.  It  is  reaUy  surprising  to  find  with  what  ease  all 
parts  of  the  lung  can  be  brought  forward  to  the  wound 
made  by  the  elevation  of  the  4th  or  5th  rib,  incised,  and 
carefully  sutured.  The  root  of  the  lung  is  almost  inuno- 
bile.  The  operator  must  go  down  to  it;  he  cannot  bring 
the  parts  nearer  to  him.  All  the  steps  of  the  operation 
can,  and  should  be,  visible  to  the  surgeon;  nothing  need 
be  done  in  the  dark;  but  the  remoteness  and  the  immobil- 
ity render  all  manipulations  much  more  difficult  than  they 
are  elsewhere.    All  technical  procedures  at  the  root  of  the 


^38  ESSAYS  ON  SURGICAL  SUBJECTS 

lung  are  made  easier  if  the  parts  near  the  hilum  are  fixed 
by  the  special  hght  forceps  of  Duval.  They  not  only 
withdraw  the  lung  from  the  path  of  the  surgeon,  but  give 
a  stable  field  in  which  to  work. 

The  physical  properties  of  the  root  of  the  lung  make  it 
exceedingly  difficult  to  distinguish  a  bronchus  from  a  piece 
of  metal.  I  have  been  deceived  more  than  once.  When, 
for  purposes  of  comparison,  I  have  examined  the  hilum  in 
cases  where  it  was  known  that  no  foreign  body  was  lodged 
there,  I  have  realized  how  exact  was  the  mimicry  of  a  pro- 
jectile by  the  hard,  rounded,  but  irregular  condition  of  a 
bronchus. 

Notwithstanding  these  several  points,  there  is  no  need 
to  modify  the  ordinary  open  procedure  which  I  have  de- 
scribed. Some  surgeons  have  preferred  the  flap  opera- 
tion, which,  as  Le  Fort  has  shown,  is  especially  appHcable 
in  some  operations  involving  the  mediastinum.  That 
more  room  is  thereby  gained  is  indisputable;  but  more 
room  is  never  needed,  for  all  requisite  manipulations  are 
possible  through  the  ordinary  incision.  The  flap  method 
is  certainly  a  little  more  formidable;  inflicts  a  greater  dam- 
age on  the  chest;  and  impKes  a  more  protracted  conva- 
lescence, and  perhaps  a  weaker  chest  wall  in  days  to  come. 

Le  Fort  himself  {Bull,  et  Mem.  Soc.  de  Chir.,  1917,  p. 
1142)  obtains  adequate  room  by  making  an  intercostal 
incision,  dividing  the  costal  cartilages  above  and  below, 
and  displacing  them  upwards  and  downwards  by  strong 
retractors.  An  approach  to  the  hilum  from  behind  is  ad- 
vised by  Petit  de  la  Villeon  {Bull,  et  Mem.  Soc.  de  Chir., 
1918,  p.  976),  who  describes  an  area  bounded  on  the  inner 
side  by  the  spine,  on  the  outer  by  the  border  of  the  scapula, 
above  by  the  5th  rib,  and  below  by  the  8th  rib,  as  that  in 
which  the  shadow  of  the  root  of  the  lung  falls.    If  a  piece 


THE  SURGERY  OF  THE  CHEST  239 


of  metal  is  seen  in  this  area,  and  is  gauged  to  be  at  a  depth 
of  from  6  to  13  cm.  from  the  posterior  sm-face,  it  lies  in  the 
root  of  the  lung.  His  operation  is  practised  in  three 
stages: 

Stage  i. — Performed  in  a  strong  red-orange  light.  The 
patient  Kes  prone.  The  omovertebral  space  is  opened,  and 
resection  of  the  necessary  ribs  (6th,  7th,  and  8th)  is  per- 
formed; the  resection  is  made  as  wide  as  possible  to  give 
free  access.    The  pleura  is  opened. 

Stage  2. — Performed  under  ar-ray,  with  screen  examina- 
tion. A  long  pair  of  forceps  is  passed  through  the  visceral 
pleura  and  the  lung  to  the  hilum.  Guided  by  the  image 
on  the  screen,  the  forceps  seizes  the  foreign  body,  grasps 
it,  and  is  held  steady. 

Stage  3. — In  daylight.  The  forceps  is  withdrawn  with 
the  projectile.  Into  the  wound  made  by  the  forceps  the 
surgeon  plunges  his  left  index-finger;  this  he  gradually 
withdraws,  packing  gauze  in  long  strips  into  the  cavity  it 
occupied.  The  wound  in  the  parietes  is  closed.  The 
packing  remeiins  for  forty-eight  hours,  being  loosened  first 
by  hydrogen  peroxide.  It  is  thought  that  the  free  pneu- 
mothorax aids  in  haemostasis.  Sixteen  cases  are  recorded, 
with  16  recoveries.     In  none  was  there  any  haemorrhage. 

The  method  of  Petit  de  la  Villeon  has  obtained  a  degree 
of  success  denied  to  all  other  procedures.  It  requires  a 
special  installation  of  hght  and  x-ray,  and  an  apprentice- 
ship on  the  part  of  the  operator  in  the  extraction  of  foreign 
bodies  under  screen  examination.  Its  success  depends 
upon  details;  but  its  success  is  no  detail.  Probably  a 
combination  of  the  anterior  operation  with  a  screen  ex- 
amination at  the  time  of  searching  within  the  hilum  for  the 
projectile  would  be  an  improvement  upon  the  original 
method.    And  no  small  part  of  the  success  of  the  opera- 


240  ESSAYS  ON  SURGICAL  SUBJECTS 

tions  performed  by  Petit  de  la  Villeon  depend  upon  his 
fully-trained  capacity  for  details  and  for  dainty  operations 
of  this  type. 

5.  Operations  Upon  the  Mediastinum: 

Access  to  the  mediastinum  may  be  obtained  either  by 
the  operations  already  described,  in  which  one  rib  alone 
is  elevated  or  removed,  or  by  methods  specially  devised 
to  give  ample  access.  Of  these  special  methods  the  fol- 
lowing may  be  briefly  described. 

1.  The  costal  flap  with  external  hinge  of  Dehrmey  modi- 
fied by  Le  Fort  (whose  description  I  give) : 

This  flap  is  cut  widely  and  regularly  by  dividing  the 
costal  cartilages  and  the  intercostal  spaces  at  equal  dis- 
tance from  the  bordering  ribs  (so  as  to  permit  the  repair 
of  the  waU) ;  it  is  then  raised,  guarded  against  fracture  of 
the  ribs  either  by  simple  elevation  if  the  flap  can  be  ex- 
tended very  far  outward,  as  is  the  case  with  the  lower  ribs, 
or  by  causing  a  greenstick  fracture  by  strong  but  cautious 
pressure,  as  can  be  done  in  the  majority  of  patients  up  to 
and  even  above  thirty  years  of  age. 

This  procedure  provides  the  most  hght,  permitting 
complete  exploration  of  the  entire  thoracic  cavity,  from 
the  clavicles  as  far  as  the  diaphragm,  and  from  the  ster- 
num to  the  vertebral  column  and  the  ribs  behind.  It  facil- 
itates aU  manipulations,  the  introduction  of  both  hands 
and  instruments  into  the  interior  of  the  thorax,  and  the 
direct  inspection  of  the  entire  cavity.  Very  recently  I 
succeeded  without  difficulty  in  obtaining  haemostasis  of  the 
wounded  azygos  major  vein  behind  the  diaphragm,  by 
means  of  an  anterior  flap. 

2.  Le  ForVs  method  of  intercostal  incision  associated  with 
division  of  the  supra-  or  subjacent  costal  cartilages: 

As  in  the  case  of  the  flap  with  an  external  hinge  of 


THE  SURGERY  OF  THE  CHEST  Ui 


Delorme,  the  procedure  causes  no  mutilation  of  the 
thorax.  The  repair  of  the  wall  is  easier  and  can  be  made 
even  more  accurately  than  after  the  Delorme  flap,  and  the 
operation  is  perhaps  even  more  free  from  danger.  The 
procedure  permits  the  breach  in  the  chest  wall  to  be  made 
more  or  less  extensive  according  to  the  necessities  of  the 
case.  A  simple  incision  of  one  intercostal  space  permits 
separating  the  ribs  by  about  6  cm. ;  division  of  the  cartilage 
above  or  below  permits  of  a  separation  of  8  cm. ;  division 
of  both  cartilages  together  gives  an  opening  of  about  12 
cm.,  and  the  supplementary  division  of  another  cartilage 
enables  one  to  enlarge  the  separation  to  19  cm.  It  is  very 
advantageous  always  to  make  the  incision  in  an  intercostal 
space  shghtly  below  the  level  of  the  foreign  body  which  is 
to  be  extracted.  This  way  of  proceeding  has  a  twofold 
advantage:  on  the  one  hand,  the  avenue  of  access  supphed 
by  the  incision  of  an  intercostal  cartilage  is  so  much  the 
larger  the  lower  the  intercostal  space;  on  the  other  hand, 
the  intercostal  incision  combined  with  incision  of  the 
costal  cartilages  above  can  be  very  easily  transformed  into 
a  costal  flap  by  simple  section  of  a  higher  intercostal  space. 
3.  The  sternocleidocostalflap  method^  suggested  by  Duval: 
This  operation  provides  free  access  to  the  cervico- 
mediastinal  "cross-roads,"  to  the  arch  of  the  aorta,  the 
origin  of  the  carotids,  the  brachiocephaHc  trunks  and  the 
subclavian  veins,  the  internal  portion  of  the  apex  of  the 
lung,  and  the  entire  half  of  the  superior  mediastinum, 
without  sacrificing  the  clavicles,  without  opening  the 
sternocostoclavicular  articulations,  without  damaging  any 
organ,  vessel,  nerve,  or  important  muscle.  It  consists  in 
turning  upward  and  outward  a  flap  which  comprises  the 
clavicle,  the  first  rib,  and  the  upper  outer  segment  of  the 
sternal  manubrium  where  these  bones  are  inserted. 

16 


242  ESSAYS  ON  SURGICAL  SUBJECTS 

4.  Median  division  of  the  sternunij  pericardium,  and 
diaphragm — DuvaVs  method: 

This  provides  free  access  to  the  heart,  and  is  recom- 
mended for  certain  operations  upon  the  right  heart. 
Sometimes  it  may  be  desirable  to  add  to  the  flap  with  an 
external  hinge  a  small  sternal  flap  with  an  internal  hinge, 
etc. 

The  detail  of  these  procedures  does  not  really  make 
much  difference.  The  indispensable  requirements  are  to 
provide  all  the  necessary  light  for  the  operative  interven- 
tion by  means  of  a  large  gap,  which  can  be  further  en- 
larged should  an  unexpected  necessity  arise ;  and  to  avoid 
all  permanent  mutilations,  so  as  to  permit  an  essential 
repair  of  the  thoracic  wall  after  the  completion  of  the 
operation. 

The  relative  advantages  and  difficulties  of  these  several 
methods  have  been  briefly  indicated  in  the  description  of 
each.  For  the  removal  of  small  projectiles  lying  free  in 
the  lung  which  has  no  serious  adhesions  to  the  chest  wall, 
the  method  of  Petit  de  la  Villeon  is  the  easiest,  safest,  and 
least  distm'bing. 

For  aU  foreign  bodies  in  the  hilum,  or  in  the  medias- 
tinum, or  in  the  heart,  an  open  operation  is  necessary. 
For  many  of  these  the  operation  in  which  one  rib  is  ele- 
vated and  resected  is  generally  adequate.  If  it  is  neces- 
sary to  have  more  ample  space  and  a  better  view,  the 
operations  of  Delorme,  Le  Fort,  or  Duval  wiU  be  per- 
formed. The  operation  of  Petit  de  la  Villeon,  in  which  the 
hilum  is  approached  from  behind,  appears  to  be  attended 
with  great  success,  but,  so  far  as  I  can  learn,  has  been  prac- 
tisied  only  by  him. 


THE  SURGERY  OF  THE  CHEST  24? 

D.  After-history  and  Results  of  Operation 

To  my  regret  it  has  not  been  possible  to  make  such 
comparison  as  I  consider  necessary  between  the  conditions 
of  the  patients  before  operation  and  afterwards,  especially 
months  afterwards.  The  men  upon  whom  I  have  oper- 
ated are  scattered  about  the  country  from  Aberdeen  to 
Cornwall;  most  of  them  are  back  at  work,  and  it  has  been 
quite  impracticable  to  get  them  to  come  for  a  medical  and 
radiological  examination.  In  most  of  the  cases  I  have 
therefore  to  rely  upon  the  patients'  testimony.  It  is  not 
certain  that  this  is  always  as  satisfactory  as  it  might  be; 
for  more  than  half  the  men  make  some  bitter  reference  to 
the  deaUngs  of  the  Pensions  Ministry  with  them ;  of  reduc- 
tions which  they  consider  untimely,  or  unfair,  in  the 
weekly  pension.  Some  of  the  letters  seem  to  express  a 
fear  that  a  too  favourable  report  may  result  in  a  pension, 
already  meagre,  being  further  reduced ;  but  the  evidence  is 
the  best  accessible.  I  have  accordingly  written  to  all 
patients,  and  their  answers  are  given  in  the  appended  case 
reports. 

As  a  class,  these  reports  contrast  in  a  very  striking 
maimer  with  those  which  I  received  almost  at  the  same 
time  from  some  of  the  patients  upon  whom,  in  recent 
years,  I  performed  partial  gastrectomy  for  gastric  ulcer  or 
gastric  cancer.  In  the  pleural  cases  it  is  comparatively 
rare  to  find  the  patient  saying  that  he  is  entirely  free  from 
trouble.  There  is  not  infrequent  reference  to  breathless- 
ness  on  exertion,  or  to  a  httle  pain.  There  is  rarely  any 
mention  of  cough,  and  none  of  haemoptysis.  These  two  con- 
ditions are  certainly  reheved  by  the  removal  of  the  foreign 
body;  but  the  functional  troubles  persist  in  some  de- 
gree. 


Wt  ESSAYS  ON  SURGICAL  SUBJECTS 

Does  the  persistence  of  some  of  these  symptoms  depend 
upon  the  operation  performed?  Is  it,  for  example,  a  wise 
procedure  to  separate  all  adhesions  binding  the  lung  to  the 
chest  wall?  In  the  presence  of  numerous  and  strong  ad- 
hesions there  does  not  appear  to  be  necessarily  any  pain, 
nor  any  shortness  of  breath  except  on  exertion.  It  is  true 
that  the  lung  then  acts  imperfectly,  that  it  shows  evidence 
of  coUapse  in  greater  or  less  degree.  My  hope  was  that 
the  free  and  open  operation  which  I  have  customarily 
performed,  together  with  the  fearless  separation  of  all  ad- 
hesions, might  do  something  to  restore  the  lung  to  its  full 
free  function.  And  in  some  cases  this  hope  has  certainly 
been  fulfilled.  It  is  a  very  striking  phenomenon  to  witness 
the  gradual  expansion  of  the  lung  when  thick  adhesions  are 
separated,  or  tough  heavy  membranes  stripped  from  its 
surface.  The  lung  grows  bigger  and  fuller  under  one's 
eyes,  and  it  is  evident  that  there  has  been  compression  as 
well  as  a  wilHng  collapse  on  the  part  of  the  lung.  But  in 
some  cases  the  results  that  have  followed  have  been  below 
my  expectations.  As  some  of  the  late  reports  show,  there 
is  evidence  still  of  restricted  capacity  for  breathing,  of 
effort  dyspnoea,  and  of  some  pain.  And  the  physical  ex- 
amination shows  also  that  in  some  cases  a  degree  of 
collapse  is  stiU  present.  The  most  certain  test  of  a  lung's 
free  activity  is  perhaps  afforded  by  an  inspection  of  the 
range  of  movement  of  the  diaphragm  watched  on  the  x-ray 
screen.  In  several  patients  there  has  been  witnessed  an 
increasing  range,  as  function  was  restored.  In  a  few  of 
our  patients  the  mobility  of  the  diaphragm  did  not  visibly 
increase. 

The  condition  of  the  elevated  rib  is  in  all  cases  quite 
satisfactory.  Sound  union  has  occurred;  and  the  chest 
wall  may  be  said  to  be  as  strong  and  firm  as  ever. 


THE  SURGERY  OF  THE  CHEST  245 


Summary 

The  following  is  an  epitome  of  my  experience:  49  cases 
have  been  treated  by  operation;  2  cases  have  died,  one 
from  haemorrhage  following  the  removal  of  a  projectile 
from  the  root  of  the  lung,  and  one  from  sepsis  after  the 
removal  of  an  infected  foreign  body  and  a  piece  of  clothing. 

The  late  history  has  been  obtained  in  43  cases.  The 
results  may  be  described  as  Good,  Fair,  Bad. 

1.  Good  Results. — These  patients  are,  they  say,  in  per- 
fect health,  and  are  able  to  do  heavy  work.  Of  these 
there  are  24,  equal  to  55.8  per  cent. 

2.  Fair  Results. — Some  of  these  patients  are  better 
than  before  operation,  but  still  have  some  shortness  of 
breath,  or  unusual  respiratory  trouble  when  having  a  cold, 
or  in  bad  weather.  Some  are  a  httle  better  since  the  opera- 
tion.    Of  these  there  are  14,  or  32.5  per  cent. 

3.  Bad  Results. — Two  patients  died;  3  are  unable  to  do 
any  work,  or  have  serious  respiratory  trouble,  shortness  of 
breath,  cough,  etc. 

The  position  of  the  foreign  body  in  the  49  cases  was  as 
follows: 

Left  lung.  Right  lung. 

In  upper  lobe 4  4 

In  middle  lobe —  1 

In  lower  lobe 10  13 

In  root 5  2 

19  20 

In  and  adherent  to  pericardium 

In  heart  muscle 

In  diaphragm 

In  pleural  cavity  (loose) 

In  body  of  vertebra 

Not  mentioned 

?    Present  (lung  gritty  and  probably  tuberculoxw) 


10 


245  ESSAYS  ON  SURGICAL  SUBJECTS 

All  but  5  were  operated  on  by  the  ordinary  anterior 
method.  The  5  operated  on  by  direct  attack  from  behind 
show  4  with  good  ultimate  results,  1  with  fair  result. 

Eighteen  of  the  foreign  bodies  were  examined  bacteri- 
ologically;  11  were  infected  with  Staphylococcus  aureus,  or 
Streptococcus  hrevis  in  equal  numbers,  or  by  these  organ- 
isms together  with  coliform  bacilli;  7  were  sterile. 

Empyema  after  operation  developed  in  5  cases,  and  in 
each  of  these,  when  the  foreign  body  was  examined,  it 
was  found  to  be  infected.  In  12  cases  blood  collected 
after  operation  in  sufficient  quantity  to  require  aspira- 
tion. In  all  these  the  adhesions  were  dense,  and  were 
widely  separated.  These  12  include  the  5  reported  above, 
which  subsequently  developed  empyema.  Of  the  7  which 
did  not  suppurate,  only  once  was  the  foreign  body  ex- 
amined, and  it  was  sterile. 

In  10  cases  the  original  injury  had  been  followed  by 
empyema.  The  only  effect  this  had  at  the  time  of  re- 
moving the  foreign  body  was  that  adhesions  were  found  to 
be  very  dense  and  extensive.  Three  cases  were  reported 
as  having  had  haemothorax  at  the  time  of  the  original  in- 
jury; at  the  operation  for  removing  the  foreign  body,  ad- 
hesions were  dense;  in  two  of  these  three  cases  an  exceed- 
ingly thick  blanket-Uke  membrane  had  to  be  removed  by 
scissors  to  allow  the  expansion  of  the  lung. 


"THE  MOST  GENTLE  PROFESSION"^ 

Delivered  at  the  Annual  Prize  Distribution  to  the  Nursing  Staff  of  the  Leeds 
General  Infirmary,  January  21,  1921. 

The  memory  of  mipleasing  things  is  very  tenacious. 
A  century  ago  an  operation  was  attended  by  a  variety 
of  circumstances  calculated  to  arouse  dismay  and  keen 
anxiety  in  every  heart;  and  to-day  the  very  word  "opera- 
tion" sends  a  shudder  through  many  of  those  who  learn 
that  it  is  to  be  their  early  destiny.  And  this  dread  con- 
tinues, though  you  and  I  know  that  an  operation  is  an 
act  of  gentlest  mercy,  guided  and  determined  by  the 
utmost  skill,  inspired  and  controlled  at  every  stage  by 
compassion  for  the  sufferer.  To  the  word  "nurse"  a 
similar  obloquy  still  attaches.  Even  now  the  word  con- 
jures up  in  some  minds  the  picture  of  a  bibulous  and 
crapulous  hag,  unversed  in  the  simplest  rudiments  of  her 
art  and  indifferent  and  insensible  to  the  needs  of  others. 
Her  picture  has  been  drawn  by  many  hands;  it  was 
coarsely  exaggerated,  no  doubt,  even  in  Dickens'  day, 
but  the  recollection  of  it  is  still  fresh  in  many  minds, 
though  you  and  I  know  that  the  nurse  of  to-day  is  one 
of  the  most  gracious  and  most  competent  of  women,  and 
that  the  profession  of  nursing  now  attracts  the  best  type 
of  womanhood  that  this  country  can  produce. 

Difficulties  Encountered  in  Private  Nursing 

But  those  of  you  who  leave  this  hospital  to  go  out 
into  the  world  to  nurse  must  not  be  surprised  if  you 
find  that  you  are  not  welcomed  with  that  open,  eager 

» Reprinted  from  "The  Hospital,"  January  29,  1921. 
2U7 


U8  ESSAYS  ON  SURGICAL  SUBJECTS 

enthusiasm  to  which  your  training  and  your  experience 
will  fuUy  entitle  you.  In  your  hospital  life  you  are 
the  despots,  most  merciful  despots  it  is  true,  of  all  your 
patients,  who  conform  with  no  word  of  denied  or  con- 
tumacy to  all  that  is  demanded  of  them  or  imposed  upon 
them.  They  accept  without  question  the  discipline  of 
the  hospital  and  the  beneficent  rule  of  its  officers.  Of 
your  work  in  private  much  will  have  to  be  done  in  the 
homes  of  your  patients.  Happily  the  day  is  almost  past 
when  an  operation  of  any  magnitude  has  to  be  performed 
in  the  unsuitable  surroundings  of  a  private  house,  with 
all  the  makeshifts  and  dangers  inseparable  from  such 
work.  But  the  convalescence  of  surgical  cases  and  the 
whole  course  of  a  grave  medical  iUness  will  be  passed 
in  a  private  house  to  whose  rules  and  customs  you  will 
be  expected  to  conform,  in  which,  however  great  your 
competence  and  however  congenial  your  society,  you  are 
an  intruder.  You  will  be  compelled,  looking  only  to  your 
patient's  welfare,  to  intervene  between  him  and  his 
friends,  often  running  counter  to  their  wishes  and  their 
normal  practice  as  you  shelter  him  from  their  well-meant 
but  harmful  attentions.  It  will  be  one  of  your  many 
testing  times,  when  you  will  require  all  the  gifts,  all 
the  tact,  and  aU  the  accompUshments  that  your  natural 
aptitude,  or  your  long  training,  have  conferred  upon  you. 

Learn  to  Use  Knowledge  Justly 

How  are  you  to  fit  yourself  for  such  tasks,  or  to 
become  competent  to  undertake  with  highest  success  all 
the  manifold  and  arduous  responsibihties  that  lie  ahead 
of  you?  First,  you  will  need  knowledge.  To  gain  it  in 
an  adequate  degree  you  will  require  intellectual  powers 
of  no  mean  order  and  industry  above  the  average.    There 


"  THE  MOST  GENTLE  PROFESSION"  249 


is  much  to  be  learnt  of  anatomy,  of  physiology,  of  medi- 
cine, and  of  surgery;  of  the  principles  which  underlie 
the  technical  work  you  will  daily  practise.  You  will  have 
to  avoid  the  little  knowledge  which  is  dangerous  by 
delving  as  deeply  as  you  can  into  those  things  which 
apply  most  nearly  to  your  own  tasks.  It  is  better  to 
learn  intimately  the  relevant  matters  than  to  have  a 
smattering  of  many  things  that  it  is  not  within  your 
strict  province  to  know.  But  knowledge  which  is  within 
the  reach  of  everyone  who  truly  seeks  it  will  avail  you 
little  unless  it  leads  you  along  the  way  to  wisdom.  Wis- 
dom impHes  the  timely  and  rightful  apphcation  of 
knowledge.  Knowledge  may  even  be  a  pitfgJl  or  an 
encumbrance  unless  you  learn  to  use  it  justly.  To  gain 
wisdom  is  of  all  tasks  in  life  the  most  difficult,  and  it 
is  certainly  no  less  arduous  in  nursing  than  in  many  other 
of  hfe's  activities.  You  will  be  foiled  and  rebuffed  and 
disheartened,  not  once  but  many  times,  as  you  toil 
earnestly  after  it,  for  the  application  of  the  truths  you 
have  learnt  may  be  so  diverse,  the  reactions  so  unexpected 
and  perplexing,  and  the  personal  aspects  of  them  so 
capricious,  that  you  may  think  of  wisdom  as  Fracastorius 
did  of  the  beating  of  the  heart — that  it  "is  so  difficult  as 
only  to  be  comprehended  by  God.'* 

You  will  have  duties,  fewer  than  they  formerly  were, 
which  may  appear  menial  or  degrading,  and  they  will 
sometimes  need  to  be  carried  out  upon  those  who  are  the 
mere  wreckage  of  humanity.  But  drudgery  may  be  a 
blessed  thing,  and  you  may  derive  consolation  from  the 
remembrance  of  One  who  thought  it  no  ill  task  to  wash 
the  feet  of  the  humblest  of  people.  And  you  will  perhaps 
day  after  day,  especially  in  your  early  years,  be  almost 
dead  with  fatigue,  embittered  by  the  disappointments  of 


250  ESSAYS  ON  SURGICAL  SUBJECTS 

a  case  that  has  gone  wrong,  or  wounded  by  a  rebuke 
that  has  escaped  from  the  Ups  of  someone  as  weary  and 
disheartened  as  yourself.  Yet  all  the  time  you  must 
show  your  best  side,  for  you  cannot  give  real  help  to 
others  if  you  seem  careworn  or  dejected.  You  must  learn 
to  bring  an  air  of  pleasure  to  the  pursuit  of  duty.  And 
so  by  degrees  you  will  learn  that  it  is  not  only  knowl- 
edge, or  even  wisdom,  but  also,  and  chiefly,  character 
that  counts.  You  will  learn  to  deal  faithfully,  stubbornly, 
and  with  untiring  zeal  with  all  your  difficulties,  and  the 
word  "trouble"  will  vanish  from  your  vocabulary.  No 
patient  can  ever  cause  you  "trouble"  if  you  remember 
that  what  is  a  daily  and  perhaps  monotonous  event  to 
you  is  the  great  event  and  perhaps  the  sternest  trial  of  a 
lifetime  to  him.  Your  patient's  needs  are  your  oppor- 
tunity. 

The  Noblest  Function  of  Man 

You  will  soon  divine  the  great  secret  that  in  many 
patients  who  are  seriously  ill  the  restraints  which  adult 
life  impose  upon  us  all,  fall  away.  The  qualities  of 
childhood  again  emerge;  there  is  a  trustful  dependence 
upon  others;  there  is  great  need  of  sympathy  and  un- 
derstanding; there  may  be  a  little  petulance,  a  little 
fretfulness,  a  querulous  demand  for  many  things  un- 
suitable. You  may  need  great  patience,  infinite  gentle- 
ness, unfailing  forbearance,  if  you  are  to  read  your 
patient  aright,  and  to  serve  him  to  the  utmost  of  your 
capacity.  Service  is  the  noblest  and  happiest  function  of 
man.  And  to  render  the  highest  service  you  must  attune 
yourself  spiritually  with  your  patients,  so  that  you  may 
read  their  hearts,  discover  their  motives,  divine  their 
impulses,  and  lead  them  at  last  to  realise  that  you  stand 
loyally  behind  them,  or  beside  them,  to  help  them,  not 


THE  MOST  GENTLE  PROFESSION"  25 f 


over  against  them  to  thwart  them.  And  at  all  times  you 
must  keep  reticence.  Many  secrets  that  have  perhaps 
been  most  jealously  guarded  will  be  disclosed  to  you,  and 
many  of  the  most  sacred  mysteries  will  be  revealed.  You 
will  preserve  an  inviolable  silence.  For  taciturnity  is  an 
ornament,  and  in  silence  there  is  security;  if  you  repent 
once  of  your  silence  you  will  repent  ten  times  of  your 
speech.  You  will  find  help  from  the  39th  Psalm,  "I  will 
take  heed  to  my  ways  that  I  offend  not  in  my  tongue. 
I  will  keep  my  mouth  as  it  were  with  a  bridle.'*  To 
chatter  of  those  intimate  things  you  learn  under  the  seal 
of  the  confessional  as  you  work  is  a  degradation  of 
your  calling.  Gossip  tainted  with  slander  is  the  last  and 
meanest  infirmity  of  empty  minds. 

The  Nurse's  Office 

Such  are  some  of  the  quahties  required  by  a  nurse, 
and  this  then  is  the  nurse's  office.  To  be  ready  in  all 
emergency,  quick  and  competent  in  action,  courteous  in 
speech,  considerate  in  thought;  a  comfort  in  hours  of 
sorrow,  an  inspiration  and  encouragement  in  times  of 
gloom;  to  give  ease  to  many  a  weary  body  and  solace  to 
many  a  troubled  heart;  to  lift  with  strong  and  gentle 
hands  a  heavy  load  of  anguish  from  those  who  falter  and 
stumble  in  despair.  It  is  to  be  a  beacon  of  hope,  a  rock 
of  refuge,  and  a  tower  of  strength. 

If  yom*  attainments  are  these  and  your  work  of  this 
high  order,  you  are  members  of  a  profession  than  which 
none  is  gentler  or  nobler.  Your  watchwords  become 
"service  and  self-surrender."  You  do  not  seek  reward  or 
selfish  gain.  Your  work  will  be  done  in  a  professional 
spirit;  it  will  be  done,  not  in  the  most  meager  way  for  the 
utmost  gain,  but  with  all  the  energy  and  truth  that 


252  ESSAYS  ON  SURGICAL  SUBJECTS 

you  can  put  into  it.  The  true  rewards  of  honest  work 
are  neither  to  be  seen  nor  handled,  they  are  not  measured 
by  a  gold  standard  nor  by  any  material  result.  They 
are  not  acclaimed  by  the  applause  of  the  crowd.  They 
lie  within  you;  in  your  own  knowledge  that  you  have 
done  your  best,  that  you  have  striven  to  reach  your 
own  standard  of  your  highest  powers.  You  will  often, 
perhaps  always,  fail  to  reach  your  own  ideal;  but  be 
comforted.  Ideals  are  not  for  attainment,  but  for 
pursuit. 

Recognition  of  Efficiency 

If  you  enter  a  profession  and  become  adept  and 
worthy  members  of  it  you  should  receive  the  proper 
recognition  to  which  your  work  entitles  you.  The  time 
is  now  ripe,  in  my  opinion,  for  your  acceptance  by  some 
academic  body  which  shall  control  the  training  and  direct 
the  teaching  of  the  nursing  profession,  and  in  due  time 
confer  authority  by  hcence,  or  diploma,  or  degree,  upon 
those  who  have  attained  the  standard  of  efficiency  that 
is  considered  adequate.  Your  work,  whether  regarded  as 
an  intellectual  task  or  as  a  technical  accompHshment 
demanding  the  exercise  of  fine  craftsmanship,  fully  en- 
titles the  nursing  profession  to  make  such  a  demand  as 
this.  If  such  a  recognition  comes,  then  will  follow  a 
result  I  have  long  desired  to  see.  There  wiU  be  a  grading 
of  nurses  by  qualification  as  there  is  a  grading  of  medical 
men.  It  is,  I  think,  just  as  necessary  that  a  sister  in 
charge  of  a  ward,  a  theatre  sister,  or  a  matron  in  a  teach- 
ing hospital  should  bear  evidence  in  her  qualification  of 
longer  study  and  more  careful  training  as  it  is  in  the  case 
of  the  medical  stafF  of  a  teaching  hospital.  Until  some 
system  of  supervision  of  the  training  of  all  who  may  call 
themselves  nurses  and  of  the  registration  and  quahfica- 


"  THE  MOST  GENTLE  PROFESSION"  253 

tion  by  diploma  or  degree  is  introduced,  the  nursing  pro- 
fession will  not  be  cleansed  from  those  impurities  which 
still  unhappily  attach  to  it. 

The  Honour  of  the  Training  School 

In  Leeds  you  are  fortunate  in  your  school.  The  train- 
ing through  which  you  pass  here  is  as  long,  as  arduous, 
as  strict  as  it  is  anywhere  in  the  world.  And  the  honour 
of  your  school  is  of  the  highest;  it  has  been  created, 
maintained,  and  increased  by  the  great  multitude  of  your 
predecessors.  Remember  that  you  all  carry  with  you, 
wherever  you  go,  the  honour  and  good  repute  of  your 
school.  Every  one  among  you  can  add  to  that  store  of 
honour  or  detract  from  it.  Leeds  will  be  judged  by  your 
work  and  by  your  demeanour.  And  when  the  time  comes 
for  you  to  lay  your  work  aside  the  highest  praise  that 
can  be  given  to  you  will  be  that  you  have  worthily  upheld 
the  high  traditions  of  your  own  school  and  the  dignity 
of  the  most  gentle  profession. 


University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

305  De  Neve  Drive  -  Parking  Lot  17  •  Box  951388 

LOS  ANGELES,  CALIFORNIA  90095-1388 

Return  this  material  to  the  library  from  which  it  was  borrowed. 


UNIVERSITY  OF  CAUPORNU 


000  375  000     7 


^^iiii-^iiiiiiiiiiiiii'iiiiliililiiiuiiiii 


H;iiiinii>:ii!i)(!t!!ti!:i:!:i 


b 


